Hysterectomy via vaginal Natural Orifice Transluminal Endoscopic Surgery in virgin patients: a first feasibility study.

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a minimally invasive, scar-free technique that uses a vaginal colpotomy to access the peritoneal cavity. Hysterectomy via vNOTES has shown to be technically feasible and safe, with shorter hospital stay and lower postoperative pain scores. Moreover, vNOTES adds the advantages of endoscopy to those of vaginal surgery and thereby broadens the indications of a conventional vaginal hysterectomy. Virginity has been contraindicated for vNOTES so far, as vaginal accessibility can be severely reduced in virgin women. Therefore, cases of vNOTES hysterectomy in virgin patients have never been reported in the literature. The objective of this study is to assess the technical feasibility and safety of hysterectomy in virgin women. We performed a retrospective analysis of patient files of all vNOTES hysterectomies performed on virgin women in our centre (Imelda Hospital, Bonheiden, Belgium) from July 2016 until June 2020 (N = 9). Despite limited vaginal accessibility, vNOTES hysterectomy was successfully performed in all nine patients, without conversion to laparoscopy or laparotomy and without clinically relevant complications. In this first IDEAL stage 1 study, vaginal NOTES hysterectomy appears to be technically feasible and safe in virgin women.Impact statementWhat is already known on this subject? Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an emerging, minimally invasive technique that offers a safe alternative to laparoscopy and open surgery. Besides better cosmetics (scar-free technique), advantages of vNOTES hysterectomy include shorter hospital stay and less postoperative pain compared to laparoscopic hysterectomy. Moreover, vNOTES adds the benefits of endoscopy (visualisation of anatomy) to conventional vaginal hysterectomy. Virginity has been contraindicated for vNOTES so far, because the absence of uterine descent and narrow vagina in virgins is thought to complicate the vaginal approach. Therefore, vNOTES hysterectomy has never been reported in virgin patients.What do the results of this study add? In this study, we are the first to report the feasibility of performing a vNOTES hysterectomy in virgin patients. The results show that, in experienced hands, indications for vNOTES can be broadened and include virgin women.What are the implications of these findings for clinical practice and/or further research? This first report of vNOTES hysterectomy in virgin patients is only a small but important step in the evaluation of safety and efficacy of this emerging technique. Further research is needed to assess reproducibility of the findings and to carefully determine indications and contraindications of vNOTES.

Impact of transvaginal natural orifice transluminal endoscopic surgery on hysterectomy practice.

STUDY OBJECTIVE: To evaluate the impacts of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) on the hysterectomy route and concomitant adnexal surgery at the time of vaginal hysterectomy (VH). MATERIAL AND METHODS: This retrospective study analyzed all hysterectomies performed for benign indications between 1 January 2017 and 31 December 2019. The period preceding the first case of VH and vNOTES BSO was considered as Pre-vNOTES. The period starting from the date of the first case was considered as Post-vNOTES. The rates per route of hysterectomy and the rate of concomitant adnexal surgery at the time of VH were compared between the two periods. RESULTS: In hysterectomies performed by surgeons who implemented vNOTES, the proportion of the vaginal route increased from 40.1% to 94.3% (P-value < 0.001); the abdominal route decreased from 37.4% to 3.2% (P-value < 0.001); and the laparoscopic route decreased from 22.5% to 2.5% (P-value < 0.001). The rates of concomitant adnexal procedures performed at the time of VH also showed significant changes. While 39.7% of patients did not undergo any concomitant adnexal surgery during the Pre-vNOTES period, this rate dropped to 8.1% after the implementation of vNOTES (P-value < 0.001). Similarly, the rate of bilateral salpingectomy dropped from 49.3% to 14.2% (P-value < 0.001), whereas the rate of BSO increased from 6.8% to 75% (P-value < 0.001). CONCLUSION: Implementation of vNOTES has led to a significant increase in the rate of VH and the rate of concomitant BSO at the time of VH.

Evaluation of the distance from the anterior cervicovaginal junction to the anterior peritoneal reflection for anterior colpotomy during vaginal hysterectomy in Korean women.

ABSTRACT: This study aimed to know the distance of the cervicovaginal junction (CVJ) to the anterior peritoneal reflection (APR) as measured in surgical specimens, and assess the distance between the CVJ and APR to ensure safe anterior colpotomy for vaginal hysterectomy among Korean women.Patients who underwent vaginal hysterectomy were included in the analysis. According to the presence of pelvic organ prolapse or menopausal status, the distance from the CVJ to the APR was assessed preoperatively through transvaginal ultrasonography (TV-US), as well as intraoperatively using surgical specimens. The intraclass correlation coefficient was used to determine the reliability between 2 measurements.In total, 171 patients were included. The median distance from the CVJ to the APR measured on TV-US was 19.8 (3.3-41.3) mm. Meanwhile, the median distance from the CVJ to the APR measured using the surgical specimen was 26.0 (12.0-55.0) mm. The intraclass correlation coefficient for the absolute agreement between 2 measurements was 0.353 (95% confidence interval: 0.002-0.570; P < .001), which is indicative of poor reliability. The median distance from the CVJ to the APR measured using the surgical specimen did not differ significantly between the 2 groups according to pelvic organ prolapse (26.0 [12.0-55.0] vs 27.5 [17.0-55.0] mm, P = .076] and menopausal status (27.0 [15.0-55.0] vs 26.0 [12.0-55.0] mm, P = .237).TV-US does not an accurately measure the dissection plane length from the CVJ to the APR during anterior colpotomy. During vaginal hysterectomy, the median distance from the CVJ to the APR measured using the surgical specimen was 26 (12.0-55.0) mm, which can help decrease surgical complications.

Vaginal Hysterectomy Rates Before and After Implementation of a Multiple-Tier Intervention.

OBJECTIVE: To assess a multiple-tier intervention to increase vaginal hysterectomy rates. METHODS: We performed a cohort study assessing hysterectomy performance before and after implementation of a multiple-tier intervention to increase vaginal hysterectomy rates at a single tertiary care medical center. This intervention involved resident and attending education and simulation, professional development, design of a clinical pathway to assist in hysterectomy decision making, and development of a surgical mentorship program. RESULTS: Data from 698 hysterectomies (253 preintervention and 445 postintervention) were included. The preintervention time period extended from January 1, 2016, to December 31, 2017 (24 months), and the postintervention period from January 1, 2018, to February 28, 2020 (26 months). The intervention was implemented over the month of December 2017 but was not complete until January 1, 2018. The preintervention and postintervention cohorts were similar in most demographic and clinical aspects. Postintervention, the proportion of vaginal hysterectomies was higher (26.5% vs 5.5%, odds ratio 6.2, 95% CI 3.52-11.35), including in those performed for reasons other than prolapse (6.8% vs 0%, P<.001). Logistic regression revealed that prolapse, uterine weight less than 250 g, and surgery during the postintervention cohort were significantly associated with vaginal hysterectomy. Operative complications did not differ significantly by hysterectomy type. CONCLUSION: Implementation of a multiple-tier intervention was associated with an increase in vaginal hysterectomies.

Impact of a National Private Health Insurer's Prior Authorization Policy on Utilization of Vaginal Hysterectomy.

OBJECTIVES: On April 6, 2015, the largest private health insurer in the United States implemented a policy requiring prior authorization for all hysterectomies except those done as outpatient vaginal. The purpose of this policy was to increase utilization of vaginal hysterectomy; however, it is unknown whether this policy had its intended effect. We sought to analyze trends in hysterectomy routes before and after implementation of the prior authorization policy to see if utilization of vaginal hysterectomy increased. METHODS: This was a retrospective study using the Optum Clinformatics Data Mart national claims database of women enrolled in a single national private health insurer who underwent hysterectomy for any indication between January 1, 2010, and June 30, 2016. Per-quarter utilization of hysterectomy routes (abdominal, laparoscopic, vaginal, and laparoscopic-assisted vaginal) was compared between the prepolicy and postpolicy periods using interrupted time series analyses. RESULTS: Data for 305,139 hysterectomies were available-248,821 in the prepolicy period and 56,318 in the postperiod. Outpatient vaginal hysterectomy had the greatest increase in utilization of all routes and types; the average utilization per quarter in the prepolicy period was -0.61%, and this increased to 0.21% in the postpolicy period (P < 0.0001). Outpatient laparoscopic hysterectomy had the greatest decrease in utilization, with an average decrease of -1.50% per quarter. CONCLUSIONS: The prior authorization policy was associated with a short-term increase in utilization of vaginal hysterectomy.

National Analysis of Perioperative Morbidity of Vaginal Versus Laparoscopic Hysterectomy at the Time of Uterosacral Ligament Suspension.

STUDY OBJECTIVE: The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension. DESIGN: Retrospective propensity-score matched cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: We included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. INTERVENTIONS: We compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort. MEASUREMENTS AND MAIN RESULTS: The study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3-2.8; p <.01) and a higher serious complication rate (5.6% vs 3.1%, OR 1.8, 1.1-3.1; p = .02), which excluded urinary tract infection and superficial surgical site infection. The propensity score analysis was performed, and patients were matched in a 1:1 ratio between the TVH-USLS group and the TLH-USLS group. In the matched cohort, patients who underwent TVH-USLS had a higher composite complication rate than those who underwent TLH-USLS (10.3% vs 6.4%, OR 1.7, 95% confidence interval [CI], 1.1-2.7; p = .04), whereas the rate of serious complications did not differ between the groups (4.3% vs 3.1%, OR 1.4, 95% CI, 0.7-2.8; p = .4). On multivariate logistic regression, TVH-USLS remained an independent predictor of composite complications (adjusted OR 1.6, 95% CI, 1.0-2.6; p = .04) but not serious complications (adjusted OR 1.4, 95% CI, 0.7-2.8; p = .3). CONCLUSION: In this large national cohort, TVH-USLS was associated with a higher composite complication rate than TLH-USLS, largely secondary to an increased rate of urinary tract infection. After matching, the groups had similar rates of serious complications. These data suggest that TLH-USLS should be viewed as a safe alternative to TVH-USLS.

Comparison of hysterectomy cases performed via conventional laparoscopy or vaginally assisted natural orifice transluminal endoscopic surgery: a paired sample cross-sectional study.

Hysterectomy is one of the most frequent gynaecological procedures performed for various uterine pathologies. There are several approaches for conducting hysterectomies, including abdominal, vaginal, laparoscopic and robotic. Recently, natural orifices transluminal endoscopic surgery (NOTES) has emerged as an alternative approach for conducting hysterectomies. In this study, we aimed to compare the results of total laparoscopic hysterectomy (TLH) and vaginally assisted-NOTES (vNOTES) hysterectomy procedures for the treatment of benign gynaecological diseases. Ninety-nine patients, who underwent conventional TLH or vNOTES hysterectomies, were included in this study. The operation time, presence of per/postoperative complications, visual analogue scale (VAS) scores at postoperative sixth and 24th hours, and the duration of hospital stays were all analysed. The duration of surgery was significantly shorter in the vNOTES hysterectomy group (79.56 ± 32.54 min) compared to the TLH group (120.67 ± 38.35 min) (p: < .001). Also, postoperative hospital stays were significantly shorter in favour of the vNOTES hysterectomy group (44 ± 16.47 h) compared to the TLH group (57.86 ± 21.31 h) (p: .002). These results indicate that vNOTES hysterectomy can be a promising approach for treating a variety of different uterine pathologies and, furthermore, that it can be an alternative to TLH.Impact statementWhat is already known on this subject? A hysterectomy can be done in a variety of different ways, such as abdominal, laparoscopic, vaginal, and robotic. Even though the standard practice guidelines recommend that a vaginal hysterectomy (VH) should be the first choice of treatment, it can be challenging in cases of non-descendent and large uteruses. In such cases, NOTES hysterectomy can be an alternative option.What do the results of this study add? The study has shown that vNOTES is associated with a shorter operation and briefer postoperative hospitalisation time, in comparison to TLH.What are the implications of these findings for clinical practice and/or further research? This study speculates that vNOTES is an approach which may offer better outcomes than a conventional laparoscopy. Further randomised controlled trials with larger sample sizes, however, should be conducted in order to establish the place of vNOTES in hysterectomy surgeries.

Comparison of two natural tissue repair-based surgical techniques; sacrospinous fixation and uterosacral ligament suspension for pelvic organ prolapse treatment.

INTRODUCTION AND PURPOSE: The present study aims to compare the effectiveness and perioperative results of the natural tissue repair-based treatments sacrospinous fixation (SSF) and uterosacral ligament suspension (USLS) based on the preoperative Pelvic Organ Prolapse Quantification system (POP-Q). MATERIALS AND METHODS: Medical records of patients with stage ≥2 uterine prolapse between January 2011 and December 2016 were retrospectively examined. Preoperative POP-Q stages, demographic characteristics, perioperative results, and recurrence ratios in mid-term follow-up for patients were compared. RESULTS: Overall, 235 patients were determined according to our study's inclusion criteria. A total of 155 patients underwent vaginal hysterectomy and USLS (VH/USLS), whereas 80 patients underwent vaginal hysterectomy and SSF (VH/SSF). There were no significant differences between groups in terms of body mass index (BMI), age, and parity as well as cardiovascular disease and diabetes mellitus. There was no significant difference in terms of anatomical success and clinical success rates in the postoperative follow-up period between both groups. (p = 0.588 and 0.692, respectively). However, the assessment of results based on preoperative stages of patients revealed that recurrence and anatomical failure were higher in the stage 4 group (p < 0.001). CONCLUSION: Our findings indicate that the main determinant factor in evaluating recurrence rates is preoperative POP-Q staging of the patient. Recurrence rates significantly increase with disease stage. Consistent with studies that do not report a clear superiority for USLS or SSF, we observed no significant differences between both procedures in terms of recurrence. The effectiveness of these procedures is similar. We believe that prospective, long-term follow-up studies with larger populations are required to accurately identify preoperative risk factors and compare them with mesh techniques.

Comparison of long-term survival of total abdominal radical hysterectomy and laparoscopy-assisted radical vaginal hysterectomy in patients with early cervical cancer: Korean multicenter, retrospective analysis.

PURPOSE: The aim of this study was to compare survival outcomes of total abdominal radical hysterectomy (TARH) versus laparoscopy-assisted radical vaginal hysterectomy (LARVH) in stage IA2-IB2 cervical cancer. METHODS: 812 patients who underwent RH between 2008 and 2017 were evaluated in 3 institutions. Progression-free survival (PFS) and overall survival (OS) were analyzed with Kaplan-Meier method and compared by log-rank test. The clinical noninferiority of the LARVH to TARH was assessed with a margin of -7.2%. Noninferiority was demonstrated if the low limit of 95% confidence interval (CI) exceeded its predefined margin. RESULTS: 258 patients were treated with TARH and 252 patients with LARVH. TARH and LARVH group had similar 5-year PFS (84.4% vs 86.6%, p = 0.467) and OS rates (85.8% vs 88.0%, p = 0.919). Noninferiority of LARVH to TARH were confirmed with 5-year PFS and OS difference rates of 2.2% (95% CI -2.9-7.3, p = 0.001) and 2.2% (95% CI -2.7-7.1, p = 0.001), respectively. In subgroup of patients with tumors size >2 cm, 5-year PFS (77.6% vs 79.0%, p = 0.682) and OS rates (79.2% vs 81.5%, p = 0.784) did not differ statistically between the two groups. Noninferiority of LARVH to TARH were also confirmed with 5-year PFS and OS difference rates of 1.4% (95% CI -7.0-9.8, p = 0.046) and 2.3% (95% CI -5.8-10.4, p = 0.027), respectively. CONCLUSION: LARVH showed significant noninferiority for PFS and OS versus TARH in early cervical cancer, suggesting the potential oncologic safety of LARVH.

Risk Factors for Bowel Injury in Hysterectomy for Benign Indications.

OBJECTIVE: To estimate the incidence and risk factors for bowel injury in women undergoing hysterectomy for benign indications. METHODS: A retrospective cohort study was conducted among women undergoing hysterectomy for benign indications from 2012 to 2016 at institutes participating in the American College of Surgeons National Surgical Quality Improvement Program, including both inpatient and outpatient settings. Bowel injury was identified using Current Procedural Terminology codes as patients who underwent bowel repair at the time of hysterectomy or postoperatively within 30 days. Multivariate logistic regression models were used to control for patient clinical factors and perioperative factors. RESULTS: Bowel injury occurred in 610 of 155,557 (0.39%) included women. After bivariate analysis, factors associated with bowel injury included age, race, body mass index, American Society of Anesthesiologists classification, increased operative time, surgical approach, type of hysterectomy, lysis of adhesions, and operative indication. After adjusting for potential confounders, bowel injury was found associated with older age, surgical indication of endometriosis, and abdominal surgical approach. Compared with the surgical indication of endometriosis (n=63/10,625), the surgical indications of menstrual disorder (odds ratio [OR] 0.33, 95% CI 0.23-0.47; adjusted odds ratio [aOR] 0.33, 95% CI 0.23-0.48; n=67/34,168), uterine leiomyomas (OR 0.80, 95% CI 0.61-1.05; aOR 0.44, 95% CI 0.33-0.59; n=243/51,232), and genital prolapse (OR 0.30, 95% CI 0.20-0.45; aOR 0.41, 95% CI 0.25-0.67; n=36/20,384) were each associated with lower odds of bowel injury. Compared with the vaginal approach to hysterectomy (n=27/27,434), the abdominal approach was found to have significantly increased odds of bowel injury (OR 10.80, 95% CI 7.31-15.95; aOR 10.49 95% CI 6.42-17.12; n=401/38,106); the laparoscopic approach had smaller but significantly increased odds (OR 2.06, 95% CI 1.37-3.08; aOR 2.03 95% CI 1.24-3.34; n=182/90,017) as well. CONCLUSION: Increased risk of bowel injury is associated with endometriosis and the abdominal surgical approach to hysterectomy. These findings have implications for the surgical care of women with benign uterine disease.

Incidence and risk factors for venous thromboembolism events after different routes of pelvic organ prolapse repairs.

BACKGROUND: Venous thromboembolism events, including deep venous thrombosis and pulmonary embolism are the most common cause of preventable deaths in hospitalized patients in the United States. Although the risk of venous thromboembolism events in benign gynecologic surgery is generally low, the potential for venous thromboembolism events in urogynecologic population is significant because most patients undergoing the pelvic organ prolapse surgery have increased surgical risk factors. OBJECTIVE: This study aimed to investigate the incidence and risk factors for venous thromboembolism events within 30 days after different routes of the pelvic organ prolapse surgery in a large cohort population using the American College of Surgeons-National Surgical Quality Improvement Program. STUDY DESIGN: This retrospective cohort study used Current Procedural Terminology codes to identify pelvic organ prolapse repairs with and without concurrent hysterectomy performed during 2011-2017 in the American College of Surgeons-National Surgical Quality Improvement Program database. Demographics, preoperative length of hospital stay, operative time, preoperative comorbidities, smoking status, American Society of Anesthesiologists classification system scores, along with other variables were collected. Postoperative 30-day complications, including readmission, reoperation, and mortality, were collected. The incidence rates of venous thromboembolism, as defined by American College of Surgeons-National Surgical Quality Improvement Program, were compared among different surgical routes. Descriptive statistics were used, and logistic regression was performed to identify associations. RESULTS: Among 91,480 pelvic organ prolapse surgeries identified, 63,108 were analyzed: 43,279 (68.6%) were performed vaginally, 16,518 (26.2%) laparoscopically, and 3311 (5.2%) abdominally. A total of 34,698 (55.0%) underwent a concurrent hysterectomy. Of 63,108 subjects, 133 developed venous thromboembolism within 30 days after surgery (0.21%; 95% confidence interval, 0.18-0.25; P<.0001). More than half (60%) of venous thromboembolism events occurred within 10 days after surgery. For all surgical routes, older age (P<.041), higher body mass index (P=.002), race or ethnicity (P=.04), longer operating time (P<.0001), inpatient status (P<.0001), American Society of Anesthesiologists 3 or 4 (P<.0001), having preoperative renal failure (P=.001), and chronic steroid use (P=.02) were significantly associated with venous thromboembolism. In addition, in the vaginal pelvic organ prolapse repair group, concurrent hysterectomy (P=.03) and preoperative dyspnea (P=.01) were associated with development of venous thromboembolism. In the abdominal pelvic organ prolapse repair, concurrent hysterectomy (P=.005) and hypertension requiring medication (P=.04) were also independently associated with venous thromboembolism development (Table 1). The incidence of venous thromboembolism was highest in abdominal repairs (0.72%), followed by laparoscopic repairs (0.25%) and vaginal repairs (0.16%). After adjusting for confounders, abdominal compared with vaginal approach (adjusted odds ratio, 3.27; 95% confidence interval, 1.93-5.41; P<.0001), longer operative time (adjusted odds ratio, 1.005; 95% confidence interval, 1.003-1.006; P<.0001), older age (adjusted odds ratio, 1.020; 95% confidence interval, 1.00-1.037; P=.015), greater body mass index (adjusted odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P=.0006), American Society of Anesthesiologists 3 or 4 (adjusted odds ratio, 1.55; 95% confidence interval, 1.03-2.31; P=.03), and preoperative renal failure (adjusted odds ratio, 8.87; 95% confidence interval, 1.16-44.15; P=.04) remained significantly associated with developing venous thromboembolism. Neither laparoscopic repair (compared with vaginal repair) nor concurrent procedures (hysterectomy, antiincontinence procedure, vaginal mesh insertion) were found to be significantly associated with the development of venous thromboembolism. The abdominal pelvic organ prolapse repairs were associated with an increased hazard of venous thromboembolism (hazard ratio, 3.27; 95% confidence interval, 1.96-5.45; P<.0001). Venous thromboembolism development was associated with 30-day mortality, readmission, and reoperation (all P<.0001). CONCLUSION: The overall incidence of venous thromboembolism after pelvic organ prolapse repairs based on a recent, large cohort database was very low, confirming the finding in previous smaller cohort studies. The highest venous thromboembolism risk was associated with abdominal route, and more than 60% of venous thromboembolism events occurred within 10 days after surgery. Thus, focus should be placed on risk-reducing strategies in the immediate postoperative period, with greater emphasis on patients undergoing abdominal surgery.

Regional variation of hysterectomy for benign uterine diseases in Switzerland.

BACKGROUND: Hysterectomy is the last treatment option for benign uterine diseases, and vaginal hysterectomy is preferred over more invasive techniques. We assessed the regional variation in hysterectomy rates for benign uterine diseases across Switzerland and explored potential determinants of variation. METHODS: We conducted a population-based analysis using patient discharge data from all Swiss hospitals between 2013 and 2016. Hospital service areas (HSAs) for hysterectomies were derived by analyzing patient flows. We calculated age-standardized mean procedure rates and measures of regional variation (extremal quotient [EQ], highest divided by lowest rate) and systematic component of variation [SCV]). We estimated the reduction in the variance of crude hysterectomy rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, cultural/socioeconomic factors, burden of disease, and density of gynecologists. RESULTS: Overall, 40,211 hysterectomies from 54 HSAs were analyzed. The mean age-standardized hysterectomy rate was 298/100,000 women (range 186-456). While the variation in overall procedure rate was moderate (EQ 2.5, SCV 3.7), we found a very high procedure-specific variation (EQ vaginal 5.0, laparoscopic 6.3, abdominal 8.0; SCV vaginal 17.5, laparoscopic 11.2, abdominal 16.9). Adjusted for procedure year, demographic, cultural, and sociodemographic factors, a large share (64%) of the variance remained unexplained (vaginal 63%, laparoscopic 85%, abdominal 70%). The main determinants of variation were socioeconomic/cultural factors. Burden of disease and the density of gynecologists was not associated with procedure rates. CONCLUSIONS: Switzerland has a very high regional variation in vaginal, laparoscopic, and abdominal hysterectomy for benign uterine disease. After adjustment for potential determinants of variation including demographic factors, socioeconomic and cultural factors, burden of disease, and the density of gynecologists, two thirds of the variation remain unexplained.

Perioperative Outcomes of Total Vaginal Hysterectomy in Women with Prior Cesarean Delivery.

STUDY OBJECTIVE: To compare the incidence of perioperative complications of total vaginal hysterectomy (TVH) in women with and without a prior cesarean section (CS). DESIGN: Retrospective cohort. SETTING: Tertiary care academic institution. PATIENTS: A total of 742 women who underwent TVH over a 5-year period. INTERVENTIONS: TVH. MEASUREMENTS AND MAIN RESULTS: Prior CS did not increase the overall rate of Clavien-Dindo grades 2 to 3 complications (p =.20). The incidence of cystotomy (2.2% CS vs 1.1% no CS, p =.29), ureteral injury (1.1% vs 0.2%, p =.23), proctotomy (1.1% vs 0.2%, p =.23), postoperative bleeding (1.1% vs 0.6%, p =.47), or reoperation (0.0% vs 0.3%, p = 1.00) was not increased from having a prior CS. Prior CS increased blood transfusion (5.6% vs 0.6%, p <.05) but did not increase conversion to laparotomy (2.2% vs 0.6%, p =.15), length of hospitalization (11.2% vs 14.1% discharge on the same day, 66.3% vs 63.6% discharge on postoperative day 1, and 22.5% vs 22.4% discharge on or after postoperative day 2, p =.76), or 30-day readmission rates (1.1% vs 3.5%, p =.34). CONCLUSION: In patients who underwent TVH, a prior CS increased postoperative blood transfusion but did not increase the risk for overall perioperative complications.

Complications after benign hysterectomy, according to procedure: a population-based prospective cohort study from the Danish hysterectomy database, 2004-2015.

OBJECTIVE: To compare the risk of complications associated with benign hysterectomy according to surgical procedure. DESIGN: Register-based prospective cohort study. SETTING: Danish Hysterectomy Database, 2004-2015. POPULATION: All Danish women with benign elective hysterectomy (n = 51 141). METHODS: Multivariate log-binomial regression to compute relative risks (RRs) stratified by calendar period, and adjusted for age, height, weight, smoking habits, use of alcohol, comorbidity, indications, uterine weight and adhesions. Multiple imputation and 'intention to treat' analyses were performed. MAIN OUTCOME MEASURES: Major (grades III-V) and minor (grades I-II) Clavien-Dindo modified complications within 30 days. RESULTS: Overall, major complications occurred in 3577 (7.0%) hysterectomies and minor complications occurred in 4788 (9.4%). The proportions of major and minor complications according to type of hysterectomy were: 10.3 and 9.6% for abdominal hysterectomy (AH); 4.1 and 12.1% for laparoscopic hysterectomy (LH); and 4.9 and 8.0% for vaginal hysterectomy (VH) for non-prolapse, and 2.3 and 6.4% for prolapse. In multivariate analyses, compared with VH for non-prolapse, the risk of major complications was higher for AH (RR 1.82, 95% CI 1.63-2.03) but lower for both LH (RR 0.78, 95% CI 0.68-0.90) and VH for prolapse (RR 0.55; 95% CI 0.41-0.75). For LH, the risk of major complications reduced from a RR of 0.96 (95% CI 0.75-1.22) in the time period 2004-2009 to an RR of 0.72 (95% CI 0.60-0.87) between 2010 and 2015. CONCLUSION: Laparoscopic hysterectomy and VH for uterine prolapse are associated with fewer major complications, and AH is associated with more major complications, compared with VH performed in the absence of uterine prolapse. TWEETABLE ABSTRACT: Laparoscopic hysterectomy has fewer major complications compared with vaginal hysterectomy, in the absence of uterine prolapse.

Surgical Trends and Time Frame Comparison of Surgical Types of Hysterectomy: A Nationwide, Population-based 15-year Study.

STUDY OBJECTIVE: To investigate the surgical trends among different types of hysterectomy (abdominal, vaginal, laparoscopic, and subtotal) over a 15-year period in Taiwan. DESIGN: A retrospective cohort study. SETTING: A population-based National Health Insurance Research Database. PATIENTS: Women undergoing various types of hysterectomy for noncancerous lesions. INTERVENTIONS: Data for this study were extracted from the inpatient expenditures by admissions files of Taiwan's National Health Insurance Research Database from 1998 through 2012 and divided into three 5-year time frames: first (1998-2002), second (2003-2007), and third (2008-2012). The variables included types of hysterectomy, patient age, gynecologist age and sex, hospital accreditation level, and surgical volume. Chi-square and trend tests were used to examine the association between the variables. MEASUREMENTS AND MAIN RESULTS: A total of 329 438 patients who underwent various types of hysterectomy were identified; 306 257 were included in the study. During the 15-year period, 45% underwent total abdominal hysterectomy, 41% underwent laparoscopic hysterectomy (LH), 9.8% underwent vaginal hysterectomy, and 4.2% underwent subtotal abdominal hysterectomy. The frequency of LHs increased from 35.9% in the first period to 43.9% in the second period and remained at 44.2% in the third period. During the same time period, there was a decrease in the frequency of total abdominal hysterectomies. Typically, younger patients underwent LHs by gynecologists with large volume surgical practices and medical centers. CONCLUSION: This 15-year study describes an increase of LHs and subtotal abdominal hysterectomies over time and provides evidence of surgical trends and a paradigm shift of hysterectomies. Surgical skills and performance extended from high- to low-surgical volume gynecologists and from medical centers to regional and local hospitals. This shift may have a great influence on patient and health care provider choice of treatment.

Apical Suspension Utilization at the Time of Vaginal Hysterectomy for Pelvic Organ Prolapse Varies With Surgeon Specialty.

OBJECTIVE: To evaluate whether utilization of apical suspension procedures at the time of vaginal hysterectomy for pelvic organ prolapse varies with surgeon specialty. METHODS: This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2016. International Classification of Diseases, Ninth Revision, Clinical Modification with a diagnosis of pelvic organ prolapse who underwent vaginal hysterectomy with any combination of pelvic reconstructive procedures. Propensity score matching using available preoperative clinical data was used to ameliorate selection bias by specialty at a ratio of 1 female pelvic reconstructive surgeon (FPMRS) surgeon to 2 obstetrician-gynecologists (OBG). Descriptive statistics were reported as means with standard deviations. Pairwise analysis using Student t test and Fisher exact test was performed where appropriate. RESULTS: After propensity score matching, there were 901 cases performed by FPMRS and 1802 performed by OBG. The overall utilization rate of apical suspension in the matched cohort was 81.7% for FPMRS and 19.8% for OBG (P < 0.001). Obstetrician-gynecologists were more likely to perform vaginal hysterectomy without apical suspension compared with FPMRS (44.3% vs 5.8%; P < 0.001) and were also more likely to perform nonapical vaginal repair without also performing an apical suspension, (17.7% vs 9.3%, P < 0.001), compared to urogynecologists. On multivariable logistic regression, having surgery performed by FPMRS was the only significant variable associated with an increased likelihood of undergoing apical suspension (adjusted odds ratio, 5.34; 95% confidence interval, 4.48-6.36). CONCLUSIONS: The FPMRS physicians are more likely to perform apical suspension with vaginal hysterectomy for prolapse repair compared with OBG.

Adnexectomy at the time of vaginal hysterectomy for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Preoperative counseling about salpingectomy with pelvic surgery is recommended by the American College of Obstetrics and Gynecology for ovarian cancer risk reduction. Our objective was to determine recent practice patterns and patient factors associated with salpingectomy with vaginal hysterectomy (VH) for pelvic organ prolapse (POP) in the USA. We hypothesize that salpingectomy might have become more common in recent years. METHODS: We queried the 2014-2016 National Surgical Quality Improvement Program database for women with a postoperative diagnosis of POP who underwent VH with any combination of pelvic reconstructive procedures. CPT codes do not differentiate salpingectomy from salpingo-oophorectomy, so subjects were stratified by whether concurrent adnexectomy was performed. Chi-squared and multivariate logistic regression analyses were used to evaluate characteristics associated with adnexectomy. Propensity score matching was utilized when evaluating postoperative complication rates. RESULTS: Of 5,344 women who underwent VH, 2019 (37.8%) had adnexectomy. Adnexectomy rate increased from 34.4% in 2014 to 46.8% in 2016 (p < 0.001). Adnexectomy rates of fellowship-trained urogynecologists and general gynecologists were similar (36.0% vs 38.8%, p = 0.197). On logistic regression analysis, patients more likely to undergo adnexectomy were < 65 years old (OR 0.844, CI 0.75-0.95, p = 0.004), had BMI <30 (OR 0.76, CI 0.68-0.86, p < 0.001), and were non-smokers (OR 0.78, CI 0.64-0.95, p = 0.016). Mean operative time was 17 min longer with adnexectomy (145 vs 128 min, p < 0.001). There were no differences in postoperative complications or reoperation rates between groups. CONCLUSIONS: Adnexectomy during VH for POP is safe and increasingly utilized by gynecology surgeons in the USA.

Minimizing Risks in Minimally Invasive Surgery: Rates of Surgical Site Infection Across Subtypes of Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To compare the 30-day incidence of deep or organ-space and/or superficial incisional surgical site infections (SSIs) by the subtype of laparoscopic hysterectomy and to report on additional risk factors for SSIs following laparoscopic hysterectomy. DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program Database. PATIENTS: Women undergoing laparoscopic hysterectomy from 2012 to 2014. INTERVENTIONS: Women were stratified into 3 groups by the type of hysterectomy: total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), and laparoscopic supracervical hysterectomy (LSCH). Demographic and clinical characteristics were compared for the 3 groups using the Kruskal-Wallis test or 1-way analysis of variance, where appropriate, for continuous variables and the chi-square or Fisher's exact test for categoric variables. Post hoc analyses were performed for multiple comparisons. Univariate analyses to examine the association with SSI were performed using the t test or Wilcoxon rank sum test as appropriate for continuous variables and the chi-square test or Fisher's exact test as appropriate for categoric variables. Significant variables on univariate analysis were included in a stepwise, backward multivariable logistic regression to identify the independent risk factors of SSI. MEASUREMENTS AND MAIN RESULTS: In total, 46 755 women underwent laparoscopic hysterectomy. Most were classified as TLH (26 009, 56%), followed by LAVH (13 884, 30%), and LSCH (6862, 14%). The overall rate of 30-day deep or organ-space SSI was 1.8% (n = 445). Thirty-day deep or organ-space SSI was lower in women who underwent LSCH (0.6%) than in women who underwent TLH (1.0%) or LAVH (1.1%; p = .001), but there was no difference in the incidence of superficial incisional SSI (0.8%, 0.8%, and 0.8% for TLH, LAVH, and LSCH, respectively; p = .75). On multivariate regression analysis, LSCH remained independently associated with a decreased risk of deep or organ-space SSI (adjusted odds ratio, 0.60; 95% confidence interval, 0.43-0.84; p = .003). In addition, relative to the women who were discharged on the same day, women admitted for >24 hours had 2-fold increased odds of deep or organ-space SSI. Asian race, smoking, perioperative transfusion, dirty or infected cases, and American Society of Anesthesiologist class 3 were associated with increased odds for deep or organ-space SSI. Length of stay >24 hours and Native Hawaiian/Pacific Islander race were associated with increased odds of superficial incisional SSI. CONCLUSION: LSCH is associated with a decreased risk of deep or organ-space SSI compared with other subtypes of laparoscopic hysterectomy. Same-day discharge after laparoscopic hysterectomy is associated with decreased odds of SSI.

Sexual Function following Laparoscopic versus Transvaginal Closure of the Vaginal Vault after Laparoscopic Hysterectomy: Secondary Analysis of a Randomized Trial by the Italian Society of Gynecological Endoscopy Using a Validated Questionnaire.

STUDY OBJECTIVE: The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire. DESIGN: Secondary analysis of a prospective randomized controlled trial. SETTING: Three academic research centers. PATIENTS: Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included. INTERVENTIONS: Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications. MEASUREMENTS AND MAIN RESULTS: A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (<26.55) had a significantly higher likelihood of having a postoperative sexual disorder (p <.001). Women who received bilateral adnexectomy before menopause and those with postoperative vaginal cuff hematoma had a significantly lower postoperative FSFI score (p = .001 and p = .04, respectively). After multivariable analysis, both variables maintained at least a tendency toward an association with a lower postoperative FSFI score (odds ratio, 2.696; 95% confidence interval, 1.010-7.194; p = 0.048 and p = 0.053; odds ratio, 13.2; 95% confidence interval, .966-180.5, respectively). CONCLUSION: Transvaginal and laparoscopic cuff closures after TLH have similar sexual postoperative outcomes. A patient with sexual problems before TLH is more likely to have a low FSFI score postoperatively. Premenopausal patients undergoing bilateral ovariectomy and those with postoperative vaginal cuff hematoma have a worse postoperative sexual life. (Clinicaltrials.gov, protocol number NCT02453165, registration date May 25, 2015.).

Laparoscopic Uterosacral Ligament Hysteropexy vs Total Vaginal Hysterectomy with Uterosacral Ligament Suspension for Anterior and Apical Prolapse: Surgical Outcome and Patient Satisfaction.

STUDY OBJECTIVE: To compare anatomic and clinical cure rates as well as patient satisfaction between uterine-preserving laparoscopic uterosacral ligament suspension and total vaginal hysterectomy with uterosacral ligament suspension in women with apical and anterior prolapse. DESIGN: Single-center clinical comparative retrospective cohort study. SETTING: A female pelvic medicine and reconstructive surgery service at a tertiary teaching hospital. PATIENTS: Women with pelvic organ prolapse who underwent surgical treatment for their condition between July 2010 and December 2015. INTERVENTIONS: All women underwent laparoscopic uterosacral ligament suspension or total vaginal hysterectomy with uterosacral ligament suspension for apical and anterior prolapse. Concomitant procedures included anterior and posterior repair, as well as a midurethral sling when indicated. MEASUREMENTS AND MAIN RESULTS: Preoperative and postoperative Pelvic Organ Prolapse Quantification (POP-Q) measurements were obtained. The primary outcome was clinical cure rate. Secondary outcomes included anatomic cure rate and outcomes of site-specific POP-Q points Ba, C, and Bp for the whole cohort. Patient satisfaction was measured using the Patient Global Impression of Improvement questionnaire. During the study period, 106 women underwent transvaginal hysterectomy with uterosacral ligament suspension, and 53 women had laparoscopic uterosacral ligament suspension. At a mean follow-up of 14.7 ± 13.23 months for the vaginal group and 17.5 ± 15.84 months for the laparoscopic group (p = .29), there were significant improvements of POP-Q points Ba, C, and Bp (p < .0001 for all comparisons in both groups). The clinical cure rate was 96% in the vaginal group and 98% in the laparoscopic group (p = .50). The anatomic cure rate was 85.4% in the vaginal group and 93.75% in the laparoscopic group (p = .11) Patient satisfaction was high in both groups. CONCLUSION: In appropriately selected patients, laparoscopic uterosacral ligament suspension is a valid uterus-preserving option for women with anterior and apical prolapse, associated with high anatomic and clinical cure rates and patient satisfaction.