A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery.

OBJECTIVE: The aim was to evaluate surgical routes for benign hysterectomy in a Swedish population, including abdominal and minimally invasive surgery. STUDY DESIGN: Prospectively collected data from the Swedish National GynOp Registry 2009-2015: 13 806 hysterectomy cases were included: abdominal (AH, n = 7485), vaginal (VH, n = 3767), conventional laparoscopic (LH, n = 1539) and robotically-assisted (RAH, n = 1015). RESULTS: The VH group had the shortest operation time at 75 min, AH 97 min and RAH 104 min. LH was longest at 127 min (p < 0.005). The mean estimated blood loss was higher in the AH group (250 ml) compared to all minimally invasive surgery (MIS, 65-172 ml); p < 0.005). Conversion rates were 10% for LH, 4.8% for VH and 1.6% for RAH (p < 0.005). Hospitalization and patient-reported time to normal activities of daily living (ADL) were longer for AH compared to MIS (p < 0.005). Time to return to work was eight days longer in the AH group (35 days) compared with the MIS groups (p < 0.005). Complications were fewest in the VH group at 5.4% compared with AH 7.6% and RAH 8.7% (both p < 0.001), but did not significantly differ from the LH group at 6.6%. Overall patient satisfaction was reported to be 86-94% one year after surgery. CONCLUSION: Women operated on for benign hysterectomy with minimally invasive methods in Sweden 2009-2015 had reduced length of hospitalization, as well as time to resuming normal ADL and return to work, compared to AH. Postoperative outcome measures were improved by minimally invasive methods and MIS should preferably be used.

Patient-reported lower urinary tract symptoms after hysterectomy or hysteroscopy: a study from the Swedish Quality Register for Gynecological Surgery.

INTRODUCTION AND HYPOTHESIS: Hysterectomy is sometimes considered the cause of lower urinary tract symptoms (LUTS). We hypothesized that hysterectomy for abnormal uterine bleeding and/or symptoms of fibroids is more likely to cause LUTS than a hysteroscopic procedure for the same indications. METHODS: Two groups of women were compared: one group comprised 3,618 women who had had a hysterectomy due to abnormal uterine bleeding or symptoms of fibroids and the other group comprised 238 women who had had hysteroscopic treatment for the same indications. The main outcome measures were occurrence of LUTS before and 1 year after the surgical intervention. The frequencies of LUTS before and after surgery were compared between the groups. Binary logistic regression was used to model the odds of having postoperative urinary leakage and urgency while controlling for uterine size, surgical procedure and preoperative LUTS. RESULTS: There were no statistically significant differences between women after hysterectomy and after hysteroscopy in the frequencies of LUTS before or after surgery, when uterine size was comparable. However, there was a difference in the rates of de novo urinary incontinence between women with hysterectomy and women with hysteroscopy (7.6%, 95% CI 6.3-9.0, and 3.2%, 95% CI 1.6-6.5, respectively). Of the women with a large uterus, 58.6% (95% CI 51.5-65.5) reported relief of urinary incontinence and 85.5% (95% CI 82.3-88.4) reported relief of urinary urgency postoperatively. CONCLUSIONS: Our results suggest that it is important to individualize preoperative information in women prior to hysterectomy since the outcome concerning LUTS depends on preoperative symptoms and uterine size.

Influence of the modifiable life-style factors body mass index and smoking on the outcome of hysterectomy.

INTRODUCTION: The aim of this study was to study the impact of body mass index (BMI) and smoking on the outcome of hysterectomy and whether effects of these factors vary between abdominal, laparoscopic and vaginal hysterectomy. MATERIAL AND METHODS: Pre-, per- and postoperative (8 weeks) data were retrieved from the Swedish National Register for Gynecological Surgery on 28 537 hysterectomies performed because of a benign indication between 2004 and 2013. Multivariable logistic regression analyses were used to identify independent factors affecting the rate of complications, presented as adjusted odds ratios (adjOR) with 95% confidence intervals (CI). RESULTS: Overweight and obesity had the strongest impact on complications in the abdominal hysterectomy group. In women with a BMI ≥ 30 an increased adjOR could be seen for bleeding >1000 mL (2.90; 95% CI 2.23-3.77), peroperative complications (1.54; 95% CI 1.26-1.88), operation time >120 min (2.67; 95% CI 2.33-3.03), postoperative complications (1.21; 95% CI 1.08-1.34) and postoperative infections (1.73; 95% CI 1.50-1.99). With vaginal hysterectomy, the effect of BMI ≥ 30 could be seen in relation to excessive bleeding >500 mL (1.63; 95% CI 1.22-2.17) and operative time >120 min (2.00; 95% CI 1.60-2.50). With laparoscopic hysterectomy (LH), a BMI ≥ 30 had a higher adjOR for prolonged surgery (1.71; 95% CI 1.30-2.26). Smokers had an increased risk of postoperative infection in the abdominal hysterectomy (1.23; 95% CI 1.07-1.40) and vaginal hysterectomy groups (1.21; 95% CI 1.02-1.43) but not in the LH group. CONCLUSIONS: Body mass index and smoking had a negative effect with all hysterectomy approaches but to a lesser extent in vaginal and laparoscopic hysterectomies. This should be taken into consideration in advance of surgery to improve outcome.

Hysterectomy and incontinence: a study from the Swedish national register for gynecological surgery.

BACKGROUND: Hysterectomy is one factor that has been suggested to be a risk factor for developing stress incontinence. In Sweden, with a population of 8.86 million, a national register was set up in 1997 in order to have data for assessing the quality of gynecological surgery for benign disorders. METHODS: Data in the Swedish national register for gynecological surgery during the period 1997-2002 were investigated. Surgical methods compared during this time period were: total hysterectomy (abdominal/laparoscopic, n=198/116), subtotal hysterectomy (abdominal/laparoscopic, n=163/86), and total hysterectomy (vaginal/laparoscopic assisted vaginal, n=265/7). Patients who underwent endometrial destruction (endometrial ablation, endometrial balloon treatment, n=187) were used as a control group. Only patients with no preoperative complaints were included. Outcome measures were answers to subjective questions asked pre- and postoperatively regarding urinary problems and incontinence. RESULTS: De novo symptoms of stress incontinence, urgency and urgency incontinence, and/or mixed incontinence were noted in all groups. No differences were found among the groups. CONCLUSION: Factors other than hysterectomy should be discussed causing stress incontinence in women.

A three-armed randomized trial comparing open Burch colposuspension using sutures with laparoscopic colposuspension using sutures and laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence.

OBJECTIVE: To compare open Burch colposuspension using sutures (OC) with laparoscopic colposuspension using sutures (LCS) and laparoscopic colposuspension using mesh and staples (LCM) in women with stress urinary incontinence. DESIGN: Prospective randomized trial. SETTING: Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Göteborg, Sweden. POPULATION: Women with genuine stress urinary incontinence or mixed incontinence with a predominantly stress component attending the Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Göteborg, Sweden. METHODS: The women were assessed objectively using a 48-h frequency-volume chart, a 48-h pad test and a standardized stress test. Subjectively, the women were assessed by a questionnaire including influence on quality of life. The women were randomized to OC using sutures (n = 79), LCS (n = 53) or LCM (n = 79). Anaesthesia/operation time, blood loss, complications and other related surgical parameters were compared. Main outcome measures. Objective and subjective cure rate. RESULTS: Objective cure rates 1 year after surgery were significantly higher in the OC and LCS groups compared to the LCM group analyzed by a standardized stress test. Subjective findings were in concordance with the objective results. Performing an OC was less time consuming than performing a LCS and resulted in more blood loss compared to the two laparoscopic techniques. Patients in the LCM group had a shorter duration of catheter use and hospital stay. CONCLUSION: The use of sutures, irrespective of whether the surgical approach was laparoscopic or open surgery, was superior to the laparoscopic mesh and staple technique.

Postoperative infections and antibiotic prophylaxis for hysterectomy in Sweden: a study by the Swedish National Register for Gynecologic Surgery.

AIM: The purpose of the study was to evaluate the current use of antibiotic prophylaxis, the rate of postoperative infections, and risk factors for postoperative infections in patients undergoing elective hysterectomy for non-malignant pathology. METHODS: The study was performed during the time period July 2000 to 1 January 1 2003, using data from the Swedish National Register for Gynecologic Surgery, covering 26 of 49 clinics and approximately 50% of the Swedish population. During this time period, 3267 women undergoing elective hysterectomy for non-malignant pathology (mainly dysfunctional bleeding and fibromas) and with complete data on the use of antibiotic prophylaxis and postoperative follow up were included. A postoperative infection was considered to have developed if patients or the physician reported an infection related to the surgical site, together with reported use of antibiotic treatment. RESULTS: Among the 3267 patients, 341 (10.4%) were considered to have developed a postoperative infection. In cases where antibiotic prophylaxis had not been given, total abdominal hysterectomies and vaginal hysterectomies were associated with the highest frequency for postoperative infections P < 0.05 and P < 0.01, respectively. Notably, also women undergoing subtotal hysterectomy reported significantly lower rates of postoperative infections if prophylactic antibiotics had been given, P < 0.05. Risk factors for postoperative infection were non-use of antibiotic prophylaxis, hospital, age less than 40 years, and BMI > 30 kg/m(2). CONCLUSIONS: The study results have indicated the need of prospective clinical trials on antibiotic prophylaxis for patients undergoing supravaginal abdominal hysterectomy. Also, a need to further evaluate the current prophylactic antibiotic protocols used for obese patients and younger women undergoing any kind of hysterectomy is warranted.

A randomised trial comparing open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence.

OBJECTIVE: To compare open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence. DESIGN: Multicentre, prospective randomised trial. SETTING: Departments of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Göteborg, Borås County Hospital and Orebro University Hospital, Sweden. POPULATION: Women with genuine stress urinary incontinence or mixed incontinence with a predominantly stress component were included, and were randomised to either open colposuspension (n= 120) or laparoscopic colposuspension (n= 120). METHODS: Women were randomised to open colposuspension with sutures or laparoscopic colposuspension with polypropylene mesh and staples. Anaesthesia/operation time, blood loss, complications and other related surgical parameters were compared. MAIN OUTCOME MEASURES: Objective and subjective cure rates from 48-hour frequency-volume chart, a 48-hour pad test and a subjective assessment of the woman's incontinence and quality of life performed one year after surgery. RESULTS: Objective and subjective cure rates were higher after open compared with laparoscopic colposuspension (P < 0.001). Quality of life was improved following surgery in both groups (P < 0.0001) and the improvement was significantly greater in the open colposuspension group (P < 0.05) with regard to physical activity. Performing an open colposuspension was less time consuming (P < 0.0001), resulted in more blood loss (P < 0.0001), longer catheterisation time (P < 0.01), greater risk of urinary retention (P < 0.01) and a longer hospital stay (P < 0.0001) compared with performing a laparoscopic colposuspension. The rate of serious complications was low in both groups. CONCLUSION: Open colposuspension had a higher objective and subjective cure rate one year after surgery but with a greater blood loss, greater risk of urinary retention and a longer hospital stay than laparoscopic colposuspension.