Urodynamic and questionnaire findings in urinary incontinent women with and without diabetes. Data from a health study.

INTRODUCTION AND HYPOTHESIS: Our aim was to compare urodynamic findings in urinary incontinent (UI) women with and without diabetes. METHODS: In the extensive Lolland-Falster Health Study, women with lower urinary tract symptoms were offered urodynamic testing. After excluding 6 women with incomplete urodynamic testing and 88 women without UI, our analysis ended up including 417 women (31 with and 386 without diabetes). Student's t-test and chi-squared test were used to compare differences of urodynamic findings. Urodynamic testing consisted of a 2-day bladder diary, post-void residual urine volume, filling cystometry, pressure-flow study, cough stress test, and uroflowmetry. Three experienced physicians in urogynecology evaluated all urodynamic findings leading to an overall conclusion of the test results. RESULTS: Self-reported data showed that compared to incontinent women without diabetes, incontinent women with diabetes had more frequent leakage, a larger amount of leakage, and a higher ICIQ score. A positive ICS Uniform cough stress test was more prevalent in women with diabetes. There were no significant differences in other urodynamic findings or overall conclusion between the two groups. Controlling for age and BMI did not affect our findings. CONCLUSIONS: Women with diabetes complained more about UI, had a higher ICIQ score, and had a positive ICS Uniform cough stress test more often than women without diabetes. Based on these findings, we recommend to include the history of urinary incontinence in the care of women with diabetes. This sample consists of women from a comprehensive health study with different severity of UI. Therefore, it can serve as a reference cohort for future studies.

Hypothyroidism and urinary incontinence: Prevalence and association in a Danish, female sample from the Lolland-Falster Health study.

INTRODUCTION: We aimed to estimate the prevalence of urinary incontinence (UI) in women with hypothyroidism and subclinical hypothyroidism and to examine the association of hypothyroidism and UI. METHODS: This cross-sectional study was based on the population-based Lolland-Falster Health Study (LOFUS), Denmark. Data comprising a questionnaire, physical examination, and blood samples were collected between 2016 and 2020. Multiple logistic regression was used to estimate odds ratios (OR) and control for possible confounders: age, body mass index, diabetes, smoking, and education. RESULTS: Of 7,699 women included in the study, 7.9% had hypothyroidism, and 2.4% had subclinical hypothyroidism. The prevalence of any UI in women with hypothyroidism, subclinical hypothyroidism, and a control group (normal level of thyroid hormones) was 43.6%, 38.1%, and 39.3%, respectively. After controlling for confounders, no association between hypothyroidism and any UI (OR 1.01, 95% CI 0.85-1.20) or frequent UI (OR 1.05, 95% CI 0.84-1.32) were demonstrated. Additional, no association between subclinical hypothyroidism and any UI (OR 0.87, 95% CI 0.64-1.18) or frequent UI (OR 1.15, 95 CI 0.79-1.69) were demonstrated. CONCLUSIONS: In our female sample, the prevalence of UI was high regardless of the thyroid status. No association between hypothyroidism and any or frequent UI was demonstrated. The prevalence of hypothyroidism was 7.9%.

Validity and reliability of two Danish versions of the ICIQ-UI SF.

INTRODUCTION AND HYPOTHESIS: We aimed to assess the validity and reliability of two Danish versions of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) in a female population. We hypothesized that the questionnaires had good predictive validity, internal consistency, patient-physician agreement, construct validity, test-retest reliability, and sensitivity to change. METHODS: To test the predictive validity, we compared the ICIQ-UI SF to urodynamics (n = 153). The same answers were used for testing the internal consistency. The patient-physician agreement was assessed by comparing the self-administered questionnaire with a physician's evaluation based on telephone interviews (n = 60). To test the construct validity, we calculated the proportion of scores ≥ 1 in questionnaires completed by women defining themselves as "not suffering from involuntary urination" (n = 69). Test-retest reliability was assessed by comparing questionnaires completed twice with an interval of 2 weeks (n = 186). Sensitivity to change was evaluated by analyzing answers before and after treatment for women treated surgically for stress urinary incontinence (n = 755) and with botulinum type A toxin for overactive bladder (n = 63). RESULTS: Predictive validity: 26.6-27.6% agreement. Internal consistency: Cronbach's alpha: 0.7-0.8. Patient-physician agreement: 53.9-92.9% agreement. Some interview participants misunderstood the word "leak." Construct validity: 19% and 23% had a total score ≥ 1. Test-retest reliability: 77.0-95.7% agreement. Sensitivity to change: Significantly lower score after treatment. CONCLUSION: The ICIQ-UI SF had excellent internal consistency, patient-physician agreement, test-retest reliability, and sensitivity to change. The ICIQ-UI SF had questionable predictive validity and construct validity compared to urodynamic testing. We recommend precaution in diagnostics or research based solely on the questionnaire.

Prevalence of urinary incontinence among women with diabetes in the Lolland-Falster Health Study, Denmark.

AIMS: To investigate the prevalence of urinary incontinence (UI) and UI subtypes (stress, urgency, and mixed UI) in women with or without diabetes mellitus; and to investigate the association between diabetes and UI (any and subtypes). METHODS: A cross-sectional study based on the Lolland-Falster, Denmark population-based health study. From 2016 to 2020, clinical measurement, questionnaires, and blood tests were collected. A total of 8563 women aged 18 or older were enrolled. Data analysis included 7906 women. UI was defined as any involuntary leakage of urine during the previous 4 weeks. Multiple logistic regression was used to adjust for confounders: age, body mass index, parity, physical activity, previous gestational diabetes, education, and smoking. RESULTS: UI prevalence was 50.3% in women with diabetes and 39.3% in women without diabetes. The unadjusted and adjusted odds ratio (OR) for UI in women with diabetes was OR 1.56 (95% confidence interval [CI], 1.27-1.92) and 1.11 (95% CI, 0.88-1.38), respectively. Mixed UI was associated with diabetes after controlling for confounders. A subgroup analysis found women using multiple antidiabetic medications had increased odds of UI, 2.75 (95% CI, 1.38-5.48), after controlling for confounders. CONCLUSION: The prevalence of UI in women with diabetes was higher than in women without diabetes. The odds of UI was 56% higher in women with diabetes compared with women without diabetes but the effect was attenuated when controlling for confounders and statistically significance was not achieved. For a subgroup using multiple antidiabetic medications, the risk of UI was higher than in women without diabetes.

Reduced Complications Following Implementation of Laparoscopic Hysterectomy: A Danish Population-based Cohort Study of Minimally Invasive Benign Gynecologic Surgery between 2004 and 2018.

STUDY OBJECTIVE: To monitor and report nationwide changes in the rates of and complications after different methods for benign hysterectomy, operative hysteroscopy, myomectomy, and embolization in Denmark. To report the national mortality after benign hysterectomy DESIGN: National prospective, observational cohort study. SETTING: The Danish Hysterectomy and Hysteroscopy Database. PATIENTS: Women undergoing surgery for benign gynecologic diseases: 64 818 hysterectomies, 84 175 hysteroscopies, 4016 myomectomies, and 1209 embolizations in Denmark between 2004 and 2018. INTERVENTIONS: National meetings with representatives from all departments, annual working reports of institutional complication rates, workshops, and national guideline initiative to improve minimally invasive surgical methods. MEASUREMENTS AND MAIN RESULTS: Rates of the different methods and complications after each method with follow-up to 5 years as recorded by the database directly in the National Patient Registry. Nationwide, a decline in the use of hysterectomy, myomectomy, embolizations, and endometrial ablation. The total short-term complications were 9.8%, 7.5%, 8.9%, and 2.7% respectively, however, with a persistent risk of approximately 20% for recurrent operations within 5 years after endometrial ablation. Initially, we urged for increased use of vaginal hysterectomy, but only reached 36%. From 2010, we urged for reducing abdominal hysterectomies by implementing laparoscopic hysterectomy and reached 72% laparoscopic and robotic procedures. Since 2015, we used coring or contained morcellation for removal of large uterus at laparoscopic hysterectomy. The major and minor complication rates (modified Clavien-Dindo classification) were reduced significantly from 8.1% to 4.1% and 9.9% to 5.7% respectively. Mortality after benign hysterectomy was 0.27‰. The odds ratio for major complications after abdominal hysterectomy was 1.66 (1.52-1.81) compared to minimally invasive hysterectomy independent of the length of stay, high-volume departments, indications, comorbidity, age, and calendar year. CONCLUSION: Fifteen years with a national database has resulted in a marked quality improvement. Denmark has 85% minimally invasive hysterectomies and has reduced the number of major complications by 50%.

Pelvic organ prolapse surgery after native tissue vault suspension at hysterectomy-A prospective cohort study.

OBJECTIVE: The effect of prophylactic vaginal vault suspension during hysterectomy in prevention of subsequent development of pelvic organ prolapse (POP) is unknown. We aimed to investigate incidences and risk of POP surgery in women who had undergone hysterectomy on benign indication with and without prophylactic suspension. STUDY DESIGN: We linked the national clinical Danish Hysterectomy and Hysteroscopy Database (DHHD) to administrative registries to assess data on all total hysterectomies (1 May 2012 to 31 December 2014), suspension methods, age, POP surgery, births, obstetric complications, prescriptions, socioeconomic- and vital status. Women undergoing total hysterectomy on non-prolapse and benign indication with no prior POP surgery were included and followed from hysterectomy to POP surgery, death/emigration or end of study period (maximum 2 years). Descriptive statistics, cumulative incidence curves and multivariable Cox proportional hazard models were fitted to assess the associated risk of POP in relation to prophylactic suspension. RESULTS: We included 7625 patients undergoing total hysterectomy; of these, 6538 (85.7%) were registered with prophylactic suspension during hysterectomy and 1087 (14.3%) women were specifically registered with no suspension in the DHHD. At baseline, women undergoing hysterectomy with suspension were on average 47.1 years of age (standard error SE 0.1) compared to 48.4 years (SE 0.3) in women with no suspension (p-value <0.0001). Moreover, women with suspension differed from their counterparts with no suspension with respect to geographical site of hysterectomy, hysterectomy method, parity and income. The cumulative risk of POP surgery after two years follow-up was 0.9% and 0.5% in the suspension group and the no suspension group, respectively. In the adjusted analysis, we found no association of prophylactic suspension and risk of POP surgery, hazard ratio (HR) = 2.1 (95% confidence interval (CI) 0.8-5.3, p-value 0.13). CONCLUSION: Of all women undergoing hysterectomy for benign indication, 0.84% (N = 64) were surgically treated for POP. At two-year follow-up, there was no association between prophylactic vaginal vault suspension at time of hysterectomy and subsequent POP surgery.

No evidence of association between native tissue vault suspension and risk of pelvic pain or sexual dysfunction.

OBJECTIVE: Hysterectomy is suspected of increasing risk of subsequent pelvic organ prolapse (POP). In attempt to prevent this, several suspension methods during hysterectomy on benign indication are used as a prophylactic procedure. However, possible complications to the use of prophylactic vaginal vault suspension to prevent POP are not fully investigated. We aimed to elucidate prophylactic vaginal vault suspension as a possible cause for pelvic pain and sexual dysfunction. STUDY DESIGN: We included all women registered with a total hysterectomy on benign indication and registered with a suspension method or specifically no suspension in the nationwide Danish Hysterectomy and Hysteroscopy Database (DHHD) between 10 May 2012 and 4 September 2013 (N = 3999). A postal questionnaire on pelvic pain and sexual dysfunction was sent to women 25.8 (range 23.8-28.4) months after hysterectomy. Questions were selected from a previous study as well as from the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). We used independent samples t-tests and χ2-tests for univariate analyses. In multivariable analyses, we used log-binomial - and linear regression models adjusted for risk factors of pelvic pain and sexual dysfunction, respectively. RESULTS: The response rate was 60.3% (N = 2412). Of the respondents, 88.8% (N = 2143) were registered with a suspension method and 11.2% (N = 269) were registered with specifically no suspension. Overall, pelvic pain of any kind was reported in 24.3% (N = 576) of the respondents. In adjusted log-binomial regression, suspension did not increase risk of pelvic pain compared to no suspension (RR 0.92; 95% CI 0.75 to 1.14; p-value 0.45). In adjusted linear regression, suspension was significantly associated with less degree of sexual dysfunction (regression coefficient -0.92; 95% CI -1.70 to -0.14; p-value 0.02). CONCLUSIONS: In women undergoing prophylactic vaginal vault suspension during hysterectomy, we found less sexual dysfunction and no evidence of increased risk of pelvic pain compared to women with no vaginal vault suspension.

Reoperation for pelvic organ prolapse: a Danish cohort study with 15-20 years' follow-up.

INTRODUCTION AND HYPOTHESIS: The objectives were to determine the reoperation rate of primary pelvic organ prolapse (POP) surgery, to describe the age distribution of the women at primary surgery for those undergoing a reoperation, and to describe the incidence of second and third reoperations. METHODS: We carried out a population-based registry study of Danish women above the age of 18 years when undergoing primary surgery for POP during the period 1996-2000. Data were retrieved from the Danish National Patient Register. All women were followed until one of the following events occurred: reoperation for POP, death, emigration, or end of follow-up period. Reoperation was defined as "repeated surgery in same compartment". The cumulative incidence rate of reoperation was divided into three compartments (anterior, apical, and posterior) and was calculated using Kaplan-Meier plots. RESULTS: A total of 18,382 procedures were performed on 11,805 women. After 20 years' follow-up, the cumulated incidence rate of reoperation for POP in the anterior, apical, and posterior compartments was 12.4%, 7.9%, and 12.1% respectively. The overall rate of reoperation was 11.5%. Of women aged between 18 and 49 years of age at primary surgery, 26.9% had a reoperation, whereas in women between 50 and 90+ years of age at primary surgery, only 10.1% had a reoperation. CONCLUSIONS: This large study with up to 20 years' follow-up has found that reoperation for POP is modest, that the reoperation rate is lowest for the apical compartment, but highest in all three compartments during the first year after primary surgery. The reoperation rate peaks in the group of women who had their primary surgery before the menopause in all three compartments.

Systematic review of the limited evidence for different surgical techniques at benign hysterectomy: A clinical guideline initiated by the Danish Health Authority.

Hysterectomy for benign gynecological conditions is a common operation that has developed extensively through the last 20 years. Methods and surgical techniques vary throughout the regions in Denmark as well as internationally. Consequently, the Danish Health Authority initiated a national clinical guideline on the subject based on a systematic review of the literature. A guideline panel of seven gynecologists formulated the clinical questions for the guideline. A search specialist performed the comprehensive literature search. The guideline panel reviewed the literature and rated the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Finally, the panel weighted the evidence and formulated the clinical recommendations. Based on the limited available literature and the corresponding quality of evidence according to GRADE, the guideline panel gave the following recommendations: ↓ Subtotal hysterectomy should only be preferred over total hysterectomy after careful consideration because there are documented disadvantages such as persistent cyclic vaginal bleeding (⊕ΟΟΟ). ↑ Consider vaginal hysterectomy rather than conventional laparoscopic hysterectomy for non-prolapsed uteri when feasible (⊕ΟΟΟ). ↓ Robot-assisted laparoscopic hysterectomy should only be preferred over conventional laparoscopic hysterectomy after careful consideration because the beneficial effect is uncertain and because of the longer operating time (⊕⊕ΟΟ). ↑ Consider concomitant bilateral salpingectomy at the time of hysterectomy if the procedure is not considered to increase the risk of complications significantly (⊕ΟΟΟ). ↑ Consider vaginal vault suspension to the cardinal and the uterosacral ligaments when performing hysterectomy for non-prolapsed uteri (⊕ΟΟΟ). Though supporting evidence is missing, the guideline panel emphasizes that it is good practice not to morcellate uteri with presumed fibroids inside the peritoneal cavity (√). The recommendations serve as professional advice in specific clinical situations. The implementation of the guideline in Denmark will be monitored through the national Danish Hysterectomy and Hysteroscopy Database.

Hysterectomy technique and risk of pelvic organ prolapse repair: a Danish nationwide cohort study.

PURPOSE: The purpose was to investigate, in a large cohort, how hysterectomy technique influences the incidence of subsequent pelvic organ prolapse (POP) repair among women hysterectomized for benign conditions. METHODS: From the Danish National Patient Registry, we collected data on all hysterectomies on benign indications, and all POP operations performed in Denmark from January 1, 1977 to June 10, 2016. We excluded patients with prior POP repair. We analyzed the incidence of POP surgery by cumulative incidence curves and hazard ratio (HR) for women with and without POP diagnoses or concomitant POP repair at hysterectomy. RESULTS: In all, 178,282 women underwent hysterectomy in the study period and were included in the cohort. When examining the crude HR for the risk of POP repair after hysterectomy, vaginal hysterectomy (VH) had a threefold rise in HR compared to total abdominal hysterectomy (TAH). When restricting the analyses to women without POP at time of hysterectomy, the HR for VH decreased to 1.25. The same tendency was noticed when stratifying by compartment. In the subgroup of women without POP at hysterectomy, we found that supravaginal abdominal hysterectomy had a small increase in risk compared to TAH. Laparoscopic hysterectomy had the same risk of POP as TAH. CONCLUSIONS: Overall, we found only small differences in risk of POP repair between the different hysterectomy techniques after restricting the analyses to women without POP at hysterectomy.

Vaginal vault suspension during hysterectomy for benign indications: a prospective register study of agreement on terminology and surgical procedure.

INTRODUCTION AND HYPOTHESIS: Several suspension methods are used to try to prevent pelvic organ prolapse (POP) after hysterectomy. We aimed to evaluate agreement on terminology and surgical procedure of these methods. METHODS: We randomly chose 532 medical records of women with a history of hysterectomy from the Danish Hysterectomy and Hysteroscopy Database (DHHD). Additionally, we video-recorded 36 randomly chosen hysterectomies. The hysterectomies were registered in the DHHD. The material was categorized according to predefined suspension methods. Agreement compared suspension codes in DHHD (gynecologists' registrations) with medical records (gynecologists' descriptions) and with videos (reviewers' categorizations) respectively. Whether the vaginal vault was suspended (pooled suspension) or not (no suspension method + not described) was analyzed, in addition to each suspension method. RESULTS: Regarding medical records, agreement on terminology was good among patients undergoing pooled suspension in cases of hysterectomy via the abdominal and vaginal route (agreement 78.7, 92.3%). Regarding videos, agreement on surgical procedure was good among pooled suspension patients in cases of hysterectomy via the abdominal, laparoscopic, and vaginal routes (agreement 88.9, 97.8, 100%). Agreement on individual suspension methods differed regarding both medical records (agreement 0-90.1%) and videos (agreement 0-100%). CONCLUSIONS: Agreement on terminology and surgical procedure regarding suspension method was good in respect of pooled suspension. However, disagreement was observed when individual suspension methods and operative details were scrutinized. Better consensus of terminology and surgical procedure is warranted to enable further research aimed at preventing POP among women undergoing hysterectomy.

Incidence of pelvic organ prolapse repair subsequent to hysterectomy: a comparison between radical hysterectomy and total abdominal hysterectomy.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare the incidence of subsequent pelvic organ prolapse (POP) repair in women following radical hysterectomy versus total abdominal hysterectomy. METHODS: From the Danish National Patient Registry, we collected data on all radical hysterectomies, all total abdominal hysterectomies, and all POP operations performed in Denmark from 1 January 1977 to 31 December 2009. We excluded patients with prior POP repair, POP diagnosis, or concomitant POP repair at hysterectomy. We analyzed the incidence of POP surgery using Kaplan-Meier curves and hazard ratio (HR). RESULTS: In all, 5279 women underwent radical hysterectomy, and 63 of these underwent subsequent POP surgery. In the same period, 149,920 women underwent total abdominal hysterectomy, and 6107 of these had POP surgery subsequent to the hysterectomy. The cumulative incidence of POP surgery was significantly lower for radical hysterectomy than for abdominal hysterectomy-3.4 % and 9.5 %, respectively, at the end of the study period, yielding a crude HR of 0.36 and an adjusted HR of 0.40 in favor of the radical hysterectomy. The distribution of POP operations in the defined compartments was the same for the two types of hysterectomy. CONCLUSIONS: This study found a significantly lower incidence of subsequent POP operations among women who undergo radical hysterectomy than total abdominal hysterectomy.

Age at hysterectomy as a predictor for subsequent pelvic organ prolapse repair.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to investigate the association between patient age at the time of hysterectomy and subsequent pelvic organ prolapse (POP) surgery. METHODS: We gathered data on all benign hysterectomies and POP surgeries performed in Denmark on Danish women from 1977 to 2009 from the Danish National Patient Registry. The cohort consisted of 154,882 hysterectomized women, who were followed up for up to 32 years. Survival analysis for each age group at hysterectomy was performed using Kaplan-Meier product limit methods. RESULTS: For all hysterectomized women, we found that low age at hysterectomy yielded a lower risk of subsequent POP surgery than did hysterectomy at an older age. This difference diminished after stratification by indication; all non-POP hysterectomies had a low cumulative incidence at 8-11 % at the end of the follow-up period. For all women hysterectomized, the predominant compartment for POP surgery was the posterior. Women hysterectomized when aged over 66 years had a higher proportion of POP surgery in the apical compartment than in the other age groups (p = 0.000). CONCLUSION: Our findings indicate that age at hysterectomy only marginally influences the risk of subsequent POP surgery for women hysterectomized for indications other than POP. If POP is the indication for hysterectomy, the risk of undergoing subsequent POP surgery increases substantially.

Low adherence to cervical cancer screening after subtotal hysterectomy.

INTRODUCTION: A reason for not recommending subtotal hysterectomy is the risk of cervical pathology. We aimed to evaluate cervical cancer screening and to describe cervical pathology after subtotal and total hysterectomy for benign indications. METHODS: Data regarding adherence to screening and pathology results from the national Danish registry (Patobank) were obtained on women from a randomised clinical trial and an observational study of subtotal versus total abdominal hysterectomy from the time of surgery until 2014. RESULTS: We included 501 women (259 subtotal hysterectomies and 242 total hysterectomies). The mean follow-up time was 14.1 years, and the mean age at follow-up was 62.1 years. After subtotal hysterectomy, 9.7% were not invited for screening. Adherence to screening was 61.4%; 8.5% were not screened. After total hysterectomy, 14.5% were not invited, 6.6% adhered to screening and 65.7% were not screened. We found a minimum of one abnormal test in 28 (10.8%) after subtotal hysterectomy and one after total hysterectomy. No cervical cancers were found. CONCLUSIONS: Adherence to cervical cancer screening after subtotal hysterectomy in a Danish population is suboptimal and some patients have unnecessary tests performed after total hysterectomy. Clarification of the use of cervical/vaginal smears after hysterectomy is needed to identify women at risk of cervical dysplasia or cancer. FUNDING: Research Foundation of Region Zealand, University of Southern Denmark, Nykøbing Falster Hospital, Rigs-hospitalet and Roskilde Hospital, Denmark. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01880710.

Objective comparison of subtotal vs. total abdominal hysterectomy regarding pelvic organ prolapse and urinary incontinence: a randomized controlled trial with 14-year follow-up.

OBJECTIVE: To compare subtotal and total abdominal hysterectomy regarding objective assessment of pelvic organ prolapse, urinary incontinence and voiding function 14 years after hysterectomy for benign diseases. STUDY DESIGN: Long-term follow-up of a randomized clinical trial of subtotal vs. total abdominal hysterectomy with objective outcomes. All randomized women still alive and living in Denmark (n=304) were invited to answer a questionnaire and come for clinical examination consisting of 20-min pad weighing test, urinary flow, measurement of residual urine, POP-Q measurement for pelvic organ prolapse, 3 day voiding diary and also filled out the pelvic floor distress inventory (PFDI-20) questionnaire. RESULTS: We included 100/304 (32.9%) women (subtotal hysterectomy: 53, total hysterectomy: 47) in the clinical examinations. The study questionnaire was answered by 197 (64.8%) (subtotal: 97, total: 100), the PFDI-20 questionnaire was answered by 140 (46.1%) (subtotal: 68, total: 72). We found no difference between subtotal and total abdominal hysterectomy in the PFDI-20 scores or regarding objectively assessed urinary incontinence or pelvic organ prolapse. In the subtotal hysterectomy group, 31 (59.6%) women had objective stage 2 pelvic organ prolapse compared with 33 (70.2%) in the total hysterectomy group (P=0.27); however, only 6/31 and 9/33 had symptoms (P=0.45). There were more anterior pelvic organ prolapses in the total hysterectomy group (N=10) than in the subtotal hysterectomy group (N=4) (P=0.048). We found a higher mean maximum flow rate (Qmax) in the subtotal hysterectomy group (34.78ml/s) than in the total hysterectomy group (27.08ml/s) (P=0.042) as well as a higher mean functional capacity in the subtotal hysterectomy group (526ml) than in the total hysterectomy group (443ml) (P=0.0147) according to the voiding diary. CONCLUSION: Subtotal and total abdominal hysterectomy are comparable regarding long-term objective pelvic organ prolapse and urinary incontinence. The subtotal hysterectomy group had a higher Qmax and voided volume.

Lower urinary tract symptoms after subtotal versus total abdominal hysterectomy: exploratory analyses from a randomized clinical trial with a 14-year follow-up.

INTRODUCTION AND HYPOTHESIS: Lower urinary tract symptoms (LUTS) are common after hysterectomy and increase after menopause. We aimed to compare subtotal with total abdominal hysterectomy regarding LUTS, including urinary incontinence (UI) subtypes, 14 years after hysterectomy. Main results from this randomized clinical trial have been published previously; the analyses covered in this paper are exploratory. METHODS: We performed a long-term questionnaire follow-up of women in a randomized clinical trial (n = 319), from 1996 to 2000 comparing subtotal with total abdominal hysterectomy. Of the randomized women, ten had died and five had left Denmark; 304 women were contacted. For univariate analyses, a χ(2)-test was used, and for multivariate analyses, we used logistic regression. RESULTS: The questionnaire was answered by 197 (64.7 %) women (subtotal 97; total 100). More women had subjective stress UI (SUI) in the subtotal group (n = 60; 62.5 %) compared with the total group (n = 45; 45 %), with a relative risk (RR) of 1.39 [95 % confidence interval (CI) 1.06-1.81; P = 0.014]. No difference was seen between subtotal and total abdominal hysterectomy in other LUTS. Factors associated with UI were UI prior to hysterectomy, local estrogen treatment, and body mass index (BMI) > 25 kg/m(2). High BMI was primarily associated with mixed UI (MUI) and urgency symptoms. Predictors of bothersome LUTS were UI and incomplete bladder emptying. CONCLUSIONS: The difference in the frequency of subjectively assessed UI between subtotal and total abdominal hysterectomy (published previously) is caused by a difference in subjectively assessed SUI; UI prior to hysterectomy and high BMI are related to UI 14 years after hysterectomy. TRIAL REGISTRATION: The trial is registered on clinicaltrials.gov under Nykoebing Falster County Hospital Record sj-268: Total versus subtotal hysterectomy: http://clinicaltrials.gov/ct2/show/NCT01880710?term=hysterectomy&rank=27.

The indication for hysterectomy as a risk factor for subsequent pelvic organ prolapse repair.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to investigate whether the indication for hysterectomy was itself a risk factor for subsequent pelvic organ prolapse (POP) in Danish women who underwent hysterectomy from 1977 to 2009. METHODS: Data from 154,882 women who underwent hysterectomy for benign conditions during the period 1977 - 2009 were extracted from the Danish National Patient Register. Patients were followed up from hysterectomy to POP surgery, death/emigration, or end of study period. Hazard ratios (HR) for the first POP surgery in each woman were calculated using the Cox proportional hazards model. Survival analysis for each indication for hysterectomy was performed using the Kaplan-Meier product limit method. RESULTS: Fibroids/polyps as the indication was used as the reference when calculating HRs. After adjustment for calendar period, patient age, and hysterectomy route, the HR for POP was 6.57 (95% confidence interval 5.91 - 7.30). The HR for abnormal uterine bleeding (AUB), pain, endometriosis, and "other indications" was significantly higher than the reference. POP surgery was performed predominantly in the posterior compartment for all indications except benign ovarian tumors. CONCLUSIONS: POP as the indication for hysterectomy was associated with the highest cumulative incidence of subsequent POP surgery 32 years after hysterectomy. But the indications AUB, pain, endometriosis, and "other indications" were associated with a higher risk of subsequent POP surgery after hysterectomy than the indication fibroids/polyps. The predominant compartment for POP surgery was the posterior compartment for almost all indications. The indication for hysterectomy and the compartment in which POP surgery was performed subsequent to hysterectomy were associated.

Subtotal versus total abdominal hysterectomy: randomized clinical trial with 14-year questionnaire follow-up.

OBJECTIVE: The objective of the study was to compare long-term results of subtotal vs total abdominal hysterectomy for benign uterine diseases 14 years after hysterectomy, with urinary incontinence as the primary outcome measure. STUDY DESIGN: This was a long-term follow-up of a multicenter, randomized clinical trial without blinding. Eleven gynecological departments in Denmark contributed participants to the trial. Women referred for benign uterine diseases who did not have contraindications to subtotal abdominal hysterectomy were randomized to subtotal (n = 161) vs total (n = 158) abdominal hysterectomy. All women enrolled in the trial from 1996 to 2000 who were still alive and living in Denmark (n = 304) were invited to answer the validated questionnaire used in prior 1 and 5 year follow-ups. Hospital contacts possibly related to hysterectomy from 5 to 14 years postoperatively were registered from discharge summaries from all public hospitals in Denmark. The results were analyzed as intention to treat and per protocol. Possible bias caused by missing data was handled by multiple imputation. The primary outcome was urinary incontinence; the secondary outcomes were pelvic organ prolapse, constipation, pain, sexuality, quality of life (Short Form-36 questionnaire), hospital contacts, and vaginal bleeding. RESULTS: The questionnaire was answered by 197 of 304 women (64.8%) (subtotal hysterectomy [n = 97] [63.4%]; total hysterectomy [n = 100] [66.2%]). Mean follow-up time was 14 years and mean age at follow-up was 60.1 years. After subtotal abdominal hysterectomy, 32 of 97 women (33%) complained of urinary incontinence compared with 20 of 100 women (20%) after total abdominal hysterectomy 14 years after hysterectomy (relative risk, 1.67; 95% confidence interval, 1.02-2.70; P = .035). After a multiple imputation analysis, this difference disappeared (relative risk, 1.36; 95% confidence interval, 0.86-2.13; P = .19). No differences were seen in any of the secondary outcomes. CONCLUSION: Subtotal abdominal hysterectomy was not superior to total abdominal hysterectomy on any outcomes. More women seem to have subjective urinary incontinence 14 years after subtotal abdominal hysterectomy. This result was not confirmed by multiple imputation analysis and should be interpreted cautiously.

Clinical risk factors and urodynamic predictors prior to surgical treatment for stress urinary incontinence: a narrative review.

INTRODUCTION AND HYPOTHESIS: Knowledge about clinical risk factors and the value of urodynamic testing is important to optimize treatment strategy and secure true informed consent. METHODS: We reviewed the relevant literature to clarify the evidence regarding clinical risk factors and the predictive value of urodynamic testing in patients with urinary incontinence, where surgery is considered. Because of the paucity of evidence based on randomized controlled trials, we conducted a narrative review of the published literature. RESULTS: Clinical risk factors in terms of mixed urinary incontinence, previous incontinence surgery, body mass index (BMI) ≥ 35, age ≥ 75, and presence of diabetes mellitus were significantly related to decreased outcome of incontinence surgery. Furthermore, noninvasive and invasive urodynamic parameters indicating detrusor overactivity, voiding difficulties, low urethral pressure, and bladder-neck immobility were related to poorer outcome of surgery. CONCLUSIONS: This study summarized the available evidence regarding preoperative clinical risk factors and urodynamic parameters indicating decreased or adverse outcome of surgery, and this report also provides clinical recommendations.

Incidence and lifetime risk of pelvic organ prolapse surgery in Denmark from 1977 to 2009.

INTRODUCTION AND HYPOTHESIS: The purpose of the study was to describe the incidence of pelvic organ prolapse (POP) surgeries in Denmark during the last 30 years, age distribution over time, and the lifetime risk of undergoing POP surgery. METHODS: We carried out a population-based registry study. The setting was the Danish National Patient Registry. The sample consisted of Danish women of all ages undergoing prolapse surgery during the period 1977-2009. Data were retrieved from the Danish National Patient Registry. Prolapse surgery included surgery for any type of genital prolapse including hysterectomy due to prolapse. The main outcome measures were incidence of POP, age distribution over time, and lifetime risk of undergoing POP surgery. RESULTS: Surgical interventions for POP decreased by 47 % from 1977 (288 procedures/100,000 women) to 1999 (153 procedures/100,000 women). Subsequently, they increased to 75 % of the original incidence rate; in 2008, the incidence of total POP procedures was 201 out of 100,000 women and the incidence of women undergoing POP surgery was 139 out of 100,000 women. During the study period, the age-specific incidence of POP surgeries increased for women over the age of 65-69 years and decreased for women below that age. In 2008, the lifetime risk for an 80-year-old woman of undergoing at least one POP surgery was 18.7 %. CONCLUSIONS: The incidence of POP surgery varied up to 50 % during the study period. The age distribution changed so that more elderly and less young women had surgery in 2008 compared with 1978. Finally, we found that the lifetime risk of undergoing POP surgery for an 80-year-old was 26.9 % in 1978, 20.5 % in 1988, 17.2 % in 1998, and 18.7 % in 2008.