Costs and mortality rates of surgical approaches to hysterectomy in Brazil.

OBJECTIVE: To analyze the costs of hysterectomies performed in Brazil due to benign conditions, and to assess its hospital admittance and mortality rates. METHODS: A retrospective cohort was carried out from January 2010 to December 2014, analyzing all hysterectomies (n = 428,346) registered on the DATASUS database between January 2010 and December 2014. Data were collected through a structured questionnaire and analyzed using the SPSS 20.0 for Windows. RESULTS: Hospital admissions were 300,231 for total abdominal hysterectomies, 46,056 for vaginal hysterectomies, 29,959 for subtotal abdominal hysterectomies and 1,522 for laparoscopic hysterectomies. Mortality rates were 0.26%, 0.09%, 0.07% and 0.05% for subtotal, total abdominal, laparoscopic, and vaginal hysterectomies, respectively. Among the procedures studied, total abdominal hysterectomies had the most costs (R$217,802,574.77), followed by vaginal hysterectomies (R$24,173,490.00), subtotal abdominal hysterectomies (R$19.253.300,00) and laparoscopic hysterectomies (R$794,680.40). CONCLUSIONS: Total abdominal hysterectomies had the highest overall costs mainly because it was the most commonly performed technique. Mortality rates were greatest in subtotal abdominal hysterectomies; this, however, may be due to bias related to missing data in our database.

Costs and mortality rates of surgical approaches to hysterectomy in Brazil

ABSTRACT OBJECTIVE To analyze the costs of hysterectomies performed in Brazil due to benign conditions, and to assess its hospital admittance and mortality rates. METHODS A retrospective cohort was carried out from January 2010 to December 2014, analyzing all hysterectomies (n = 428,346) registered on the DATASUS database between January 2010 and December 2014. Data were collected through a structured questionnaire and analyzed using the SPSS 20.0 for Windows. RESULTS Hospital admissions were 300,231 for total abdominal hysterectomies, 46,056 for vaginal hysterectomies, 29,959 for subtotal abdominal hysterectomies and 1,522 for laparoscopic hysterectomies. Mortality rates were 0.26%, 0.09%, 0.07% and 0.05% for subtotal, total abdominal, laparoscopic, and vaginal hysterectomies, respectively. Among the procedures studied, total abdominal hysterectomies had the most costs (R$217,802,574.77), followed by vaginal hysterectomies (R$24,173,490.00), subtotal abdominal hysterectomies (R$19.253.300,00) and laparoscopic hysterectomies (R$794,680.40). CONCLUSIONS Total abdominal hysterectomies had the highest overall costs mainly because it was the most commonly performed technique. Mortality rates were greatest in subtotal abdominal hysterectomies; this, however, may be due to bias related to missing data in our database.

Radical vaginal trachelectomy: a fertility-preserving procedure in early cervical cancer in young women.

BACKGROUND: Radical vaginal trachelectomy (RVT) is a fertility-preserving operation for young women who have cervical cancer in an early stage and want to have children. The demand for RVT is increasing, because more than 40% of all cases of cervical carcinoma affect women under the age of 44. Women are increasingly having their first child at later ages. METHODS: We present the results of RVT in more than 300 patients whom we operated on, review pertinent literature retrieved by a selective PubMed search, and evaluate treatment recommendations. RESULTS: The literature contains data on more than 1000 women treated with RVT and nearly 300 pregnancies after RVT. The 5-year recurrence and mortality rates are 2%-5% and 3%-6%, respectively. RVT is an oncologically safe treatment for women who want to have children. The main criteria for treatment with RVT are that the tumor should be no greater than 2 cm in diameter and that the lymph nodes should be histopathologically free of tumor tissue. The laparoscopic-vaginal technique is the best operative approach to assure a high rate of healing. Only one-third of all patients want to have children a short time after RVT. Their pregnancy rates resemble those of women in the general population. 50% of the children are born prematurely, mainly because of premature rupture of the membranes. Thus, pregnancies after RVT are considered high-risk pregnancies. CONCLUSION: As many as 48% of women with early-stage cervical carcinoma meet the criteria for RVT. RVT is an oncologically safe method that enables women with early-stage cervical carcinoma to become pregnant and have children. Pregnancy after RVT is associated with an elevated risk of preterm birth and should be managed according to standardized procedures.

Comparison of survival and adverse events between women with stage IB1 and stage IB2 cervical cancer treated by laparoscopic radical vaginal hysterectomy.

PURPOSE: The goal of this study was to evaluate the operative feasibility and survival for patients with stage IB2 cervical cancer who undergo laparoscopic radical vaginal hysterectomy (LRVH) compared with those with stage IB1 cervical cancer. METHODS: We identified 90 patients who were eligible to participate in the study through retrospective analysis of medical records from March 2003 to June 2010. Patients with stage IB1 cervical cancer were divided into two groups by a cutoff value of 2 cm for tumor size. Data regarding surgicopathologic risk factors, surgical outcomes, and survival rates were compared among three groups (two with stage IB1 and one with stage IB2). RESULTS: The tumor size was ≤2 cm in 27 patients, 2-4 cm in 30, and >4 cm in 33. The number of intermediate and high-risk factors was significantly lower in patients with stage IB1 cervical cancer (≤2 cm) than in those with stage IB2. Surgical outcomes (mean operating time, estimated blood loss, number of harvested lymph nodes, and sites of metastatic lymph nodes) did not show any significant difference among the three groups. The rates of intraoperative complications also did not differ among the three groups (P = 0.833). The estimated 5-year recurrence-free and overall survival rates were not significantly different among the three groups (P = 0.253 and 0.525, respectively). CONCLUSIONS: LRVH for stage IB2 cervical cancer can be performed with similar safety and survival rates compared to stage IB1 cervical cancer. Overall, LRVH is feasible for the treatment of stage IB2 cervical cancer.

[The morbidity and mortality in vaginal hysterectomy performed with bipolar electrosurgery]. / Morbilidad y mortalidad en histerectomía vaginal por electrocirugía bipolar con biclamp.

OBJECTIVE: to know the morbidity and mortality in vaginal hysterectomy (VH) carried out with bipolar electrosurgery (BiClamp). METHODS: a multicentric study with 380 patients who underwent to VH for benign illness, with and without prolapse, with and without abdominal previous surgeries using Biclamp was carried out. RESULTS: twenty five patients (6.57 %) presented complications. The most frequent were related to the urinal system and infection, when VH was carried out. Bladder injury in five cases (1.31 %), vesicular-vagina fistula in two cases (0.52 %). Vaginal vault abscesses in seven cases (1.84 %). A second surgery due to intra abdominal bleeding in four cases (1.05 %) was carried out. Vaginal vault bleeding was present in two cases (0.52 %); other complications were: hematoma in vaginal vault, thrombophlebitis, sepsis and death with one case (0.26 %) for each one. The injuries were repaired by a gynecologist and the fistulae by an urologist. The bleeding was inmediately remedied and the infection was treated with cephalosporin. CONCLUSIONS: the morbidity and the operative mortality were in the range reported in the literature. This technique is quicker, less invasive, with a prompt patient recovery.

Comparative study of morbidity and mortality associated with nondescent vaginal hysterectomy and abdominal hysterectomy based on ultrasonographic determination of uterine volume.

This is a prospective and comparative study of 150 patients each operated on for vaginal and abdominal hysterectomy for indications other than utero-vaginal prolapse between January 2004 and December 2005. Age, parity, and anesthesia were matched in both groups. A preoperative examination under anesthesia and sonographic estimation of uterine volume were done to decide the feasibility of vaginal hysterectomy. Various debulking techniques such as hemisection, enucleation, and wedge resection were used for the vaginal route. Leiomyomas were the most common indication in both groups. The mean time taken was less in the vaginal group (39.07 versus 45.56 minutes). The average blood loss (35.36 versus 108.5 g) and the mean hospital stay (3.71 versus 7.84 days) were also significantly less in the vaginal group than in the abdominal group. The overall postoperative morbidity and period of convalescence were also reduced in the vaginal group.

Hysterectomy in the 21st century: different approaches, different challenges.

The final decision to perform a certain method of hysterectomy customarily mirrors experience and level of comfort with a particular surgical approach in the context of the patient's condition and indication for surgery. Given the morbidity and recovery associated with a laparotomic incision, every effort should be made to avoid abdominal hysterectomy. The best available evidence points to the advantage of the vaginal approach over other methods of hysterectomy for benign conditions. Regrettably, the state of education in residency programs is not providing a level of surgical competency to meet this charge. Whenever vaginal surgery is not an option, laparoscopically assisted hysterectomy offers the best alternative. Although the promises of supracervical hysterectomy have yet to be demonstrated, laparoscopic supracervical hysterectomy may offer the least morbid alternative to vaginal hysterectomy.

Audit of morbidity and mortality rates of 1792 hysterectomies.

STUDY OBJECTIVE: To audit morbidity and mortality rates of laparoscopic, abdominal, and vaginal hysterectomy. DESIGN: Retrospective review of monthly morbidity and mortality rates (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: One thousand seven hundred ninety-two women who underwent hysterectomy for benign, nonobstetric indications at the Sir Mortimer B. Davis-Jewish General Hospital. INTERVENTIONS: Laparoscopic supracervical (LASH), vaginal (VH), and abdominal (AH) hysterectomies. MAIN OUTCOME MEASURES: Morbidity outcomes of different types of hysterectomy. Reoperation, admission to the intensive care unit, discordant diagnosis, and prolonged hospitalization also were evaluated. RESULTS: We studied 223 cases of LASH, 1349 AH, and 220 VH. The overall hysterectomy-related morbidity rate was 6.1%. The rate of morbidity was higher in the LASH group (9.4%) than in the AH group (5.2%, p <.01), but no significant difference was noted between AH and VH (8.6%). The incidence of intraoperative bowel injury was 0.4% in the LASH group (a trocar injury in a patient) and 0.3% in the AH group. Bladder injury was encountered in two patients in the LASH group (0.9%) and in another two in the AH group (0.1%). Ureteral injury occurred in a patient in the AH group (0.07%). There were no cases of intraoperative vascular injury. Vaginal hysterectomy was associated with more urinary retention and hematoma formation than the other two groups. Discordant diagnosis was noted in four cases (two missed endometrial cancer, atonic and distended bladder mistaken for an ovarian cyst, and pelvic tuberculosis). The conversion rate to laparotomy was 1.7% in the LASH group and 0.4% in the VH group, and the incidence of reoperation was 0.4% in the AH group. CONCLUSIONS: The overall hysterectomy-related morbidity rate in our series is 6.1%. Compared with other types of hysterectomy, more urinary retention and hematoma formation occur after VH. Laparoscopic supracervical hysterectomy is associated with a higher morbidity rate than AH; mainly because of conversion to laparotomy and blood transfusion.

A two years audit of complications of hysterectomy at Ayub Teaching Hospital Abbottabad.

BACKGROUND: Hysterectomy is one of the most common major surgical procedures performed in Gynaecology. Our objective was to determine the operative and postoperative complications of this procedure with an aim to improve management at our unit. METHODS: This study was conducted in the Department of Gynaecology, Ayub Teaching Hospital, Abbottabad form January 2002 to December 2003. Indications, complications and mortality associated with hysterectomy were assessed. RESULTS: Total number of hysterectomies performed in two years at our unit was 316. Major Indications for hysterectomies were dysfunctional uterine bleeding (38%) and fibroid uterus, (27%) followed by prolapse (22%). Complications developed in 14% out of these. The frequency of complications was related with indication for hysterectomy, age, parity and history of associated serious illness. It was found that frequency of complications in fibroid uterus was higher (1.2%) than that for Dysfunctional uterine bleeding (DUB) (1.0%). There was no operative death, while 5 (1.5%) patients died within 2 weeks of surgery. CONCLUSION: We have a fairly high frequency of morbidity and mortality associated with hysterectomy. In order to reduce these proper selection, pre-operative preparation and less invasive alternative treatment for the commonest indications of hysterectomy (that is fibroids and DUB) for example various methods of endometrial ablation or resections can be employed.

Morbimortalidad materna en histerectomía obstétrica de urgencia / Maternal morbimortality in obstetric hysterectomy of emergency

Se realizó un estudio retrospectivo y descriptivo en el Hospital Provincial Docente Ginecobstétrico Ana Betancourt de Mora de Camagüey, desde 1997 a 2003 para conocer la morbimortalidad materna derivada de la histerectomía obstétrica. El universo y la muestra fueron de 124 pacientes histerectomizadas de urgencia en el período puerperal. Las variables estudiadas fueron la edad, los eventos obstétricos, modo del parto, momento, causas y complicaciones de este proceder. Predominaron las edades de 20 a 34 años en el estudio con 101 pacientes; el 49.2 por ciento de las operadas tuvo un parto anterior y el 75.0 por ciento provino de embarazos a término. La rotura prematura de membrana (26) y la cesárea anterior (20) fueron los eventos obstétricos más frecuentes; predominó la cesárea (50.8 por ciento ). El mayor porcentaje de histerectomía se produjo en el posparto (49.2 por ciento ) y la atonía uterina (42.8 por ciento ) constituyó la causa más frecuente. En la primera intervención (56) se ligaron mayormente las arterias hipogástricas. La sepsis (14) prevaleció como complicación. El 97.6 por ciento de las pacientes egresó viva y el 2.4 por ciento falleció(AU)

Ten-year review of hysterectomy morbidity and mortality: can we change direction?

The medical records of all women who underwent hysterectomy for benign disease performed between 1986 and 1995 were reviewed to ascertain the incidence of morbidity and mortality of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy at a university teaching hospital. A total of 1940 hysterectomies were performed during this period; 74% of hysterectomies were performed abdominally, 24% vaginally and 2% were laparoscopically assisted. In 80% of the patients uterine leiomyomas, adenomyosis, dysfunctional uterine bleeding or uterine prolapse were the indications for hysterectomy The overall complication rate was 44% for abdominal hysterectomy (AH) and 27.3% for vaginal hysterectomy (VH). An unintended major surgical procedure was required in 3% and 1% of women undergoing AH and VH respectively The rate of return to the operating room for haemostasis was 0.6% for AH and 0.2% for VH. The AH group was four times more likely than the VH group to require surgical intervention (36% versus 9%) at readmission. Vaginal hysterectomy was associated with a lower febrile morbidity and minor complication rate. Prophylactic antibiotics reduced the febrile morbidity for VH and AH by 50% (Student's t-test, p = 0.02) and 40% (Student's t-test, p < 0.001) respectively The overall mortality rate was 1.5 per 1000.

Operative injuries during vaginal hysterectomy.

OBJECTIVE: To evaluate incidence, characteristics and consequences of urinary and intestinal tract injuries during vaginal hysterectomy for benign conditions. STUDY DESIGN: From January 1970 to December 1996, 3076 vaginal hysterectomies with or without additional procedures, were performed for benign conditions in our department. We retrospectively analyzed operative injury cases. RESULTS: Incidence of urinary and intestinal tract injuries were 1.7 and 0.5%, respectively. Concerning urinary tract injuries, we observed only one ureteral lesion, all others being bladder lacerations (54 cases). The bladder lacerations occured during the hysterectomy step of the surgery in 61% of cases and during the additional procedures in 39%. All bladder injuries were recognized and treated during the primary operation. We observed four cases of vesico-vaginal fistula as a consequence of these injuries; all fistulas occured after bladder laceration during the hysterectomy step of the surgical procedure. Intestinal tract injuries (16 cases) were rectal lacerations occuring during the hysterectomy step of the surgery (31% of cases) and during the additional procedures (69%). All rectal injuries were recognized and repaired during the primary operation and all healed without sequellae. CONCLUSION: Operative injuries during vaginal hysterectomy are relatively rare. They are easily recognized and treated during the primary operation without important sequellae.

Vaginal hysterectomy as primary treatment of endometrial cancer in medically compromised women.

OBJECTIVE: To study the survival, rates and patterns of recurrence, and perioperative morbidity in medically compromised women with endometrial cancer treated by primary vaginal hysterectomy. METHODS: Fifty-one patients with endometrial cancer treated initially by vaginal hysterectomy between 1977 and 1999 were identified at the University of California, Irvine Medical Center and affiliated hospitals. Data were retrieved from hospital and office records. Statistical analysis, including Kaplan-Meier methods, was performed and the disease-specific survival rates were estimated. This study has 80% power to demonstrate a greater than 20% improvement in 5-year survival over historical controls. RESULTS: Fifty-one women with uterine carcinoma clinically confined to the uterus underwent primary vaginal hysterectomy with (n = 26) or without (n = 25) salpingo-oophorectomy. Eighty-four percent were obese with a body mass index greater than 27. Additional risk factors for surgical complications included hypertension (57%), diabetes mellitus (27%), and cardiovascular disease (18%). One-third of patients had three or more risk factors. Surgical morbidity included one episode of acute hemorrhage necessitating transfusion and abdominal exploration. Blood transfusions were given to four additional patients. There were no perioperative deaths. Five women recurred and expired at a median of 13 months (range 3--53 months) after surgery. The 3- and 5-year disease-specific survival rates were 91.4% and 88.0%, respectively. CONCLUSION: Vaginal hysterectomy for the initial treatment of early-stage endometrial cancer is associated with a high rate of cure and minimal morbidity. Thus, it may be considered a reasonable alternative to the abdominal approach in medically compromised women.

Estado actual de la morbimortalidad de la histerectomía radical en el cancer cervico uterino invasor temprano

Se presenta la experiencia adquirida sobre la histerectomia radical en 145 pacientes, analizando los variantes en la técnica con y sin sección de la arteria vesical. Observandose que dentro de los transoperatorios la complicación principal fue el sangrado especialmente en pacientes obesos y los postoperatorios infección 20,6 por ciento y patología en el detrusor urinario 17.8 por ciento con un porcentaje aceptable de fístulas 6 por ciento.

Histerectomia obstétrica de emergencia

Se realizó un estudio retrospectivo en 43 pacientes ingresadas en el Servicio de Obstetricia del Hospital Carlos Andrade Marín, desde enero de 1987 a enero de 1993, para determinar la incidencia de cesárea más histerectomía y la morbi-mortalidad de la misma, la etiología predominante así como el tipo de histerectomía realizada. Se realizó histerectomía obstétrica en 43 pacientes de las cuales el 9.3 por ciento fallecieron y el 88 por ciento evolucionaron favorablemente. Los rangos de incidencia varían entre 31 a 40 años. La edad gestacional de terminación de los ambarazos se sitúa en el 56 por ciento entre las 37 a 41 semanas. Las causas de histerectomia fueron desordenes placentarios en el 38 por ciento, hipotonía uterina en el 25 por ciento, otras (miomatosis, endometritis, pelviperitonitis, hematoma de ligamento ancho, polipo cervical, CA. de cervix y de ovario en el 25 por ciento, rotura uterina en el 10 por ciento y no se encontró dato en el 10 por ciento. El tipo de histerectomia realizada fue total y subtotal. De los 31 a 40 años la placenta previa es la mayor causa de histerectomia, en tanto que de los 20 a 25 años son rotura uterina e hipotonía.

Morbilidad en la shisterectomía Hospital Materno Infantil Germán Urquidi / Morbility in hysterectomies at the Obstetric Hospital German Urquidi

Se revisa 109 histerectomías abdominales y 20 histerectomias vaginales desde Octubre 1989 a Octubre 1991 en el servicio de Ginecología y Obstetricia del Hospital Materno Infantil Germán Urquidi. Se analiza el diagnóstico clínico, tipo de cirugía, complicaciones trans y post operatorios y los resultados son motivo de este trabajo considerando los parámetros comparativos de otros autores.

Operative outcome following vaginal hysterectomy.

The peri-operative factors surrounding the patient subjected to vaginal hysterectomy were reviewed. Most of the patients were post-menopausal, and the indication for surgery in all cases was utero-vaginal descent. Regional anaesthesia was associated with less blood loss, while lower blood losses were associated with fewer complications and shorter hospitalization. Overall, the morbidity was low (8%), and the mortality was zero.

Histerectmía vaginal: modificaciones a la técnica

Se revisaron 100 historias clínicas correspondientes a histerectomías vaginales realizadas con las modificaciones a la técnica tradicional en el servicio de Ginecología del Hospital de San Juan de Dios de Cali. Se presenta en éste trabajo una técnica quirúrgica que incluye varias modificaciones a los procedimientos clásicos tradicionalmete conocidos, las cuales se describen a continuación: 1. Evacuación de la vejiga al inicio de la cirugía y se continúa con la sonda a drenaje, obteniendo mayor descenso del útero y campo operatorio más amplio. 2. Uso de la valva de Auvard: campo operatorio más amplio sin intervención del ayudante, permitiendo la colaboración de él activamente en la operación. 3. Se identifican, pinzan y seccionan por separado los ligamentos cardinales o de Mackenrodt y los ligamentos útero-sacros y se dejan reparados. Los ligamentos de Mackenrodt se aproximan y afrontan uno a otro constituyendo una hamaca del piso pélvico. 4. Suspensión de la cúpula: los ligamentos útero-sacros se fijan a las horas 1 y 5 y a las 11 y 7 del círculo que queda al circuncidar el cuello, correspondiendo al canal vaginal; en tanto que los pedículos superiores, que al ser reparados contienen cada uno el ligamento redondo, la trompa y el ligamento útero-ovárico, se llevan a las horas 3 y 9. Esta técnica de tipo intrafacial preserva la configuración anatómica, la longitud y el eje de la vagina. La morbilidad igual que otros autores, es mínima. Creemos que la uretro-cisto-pexia, llevando los puntos a la facia pubovesical y afrontar las estructuras, restablece el ángulo vesico-uretral corrigiendo la incontinencia urinaria