The Impact of Symptoms of Depression, Anxiety, and Low Stress-Coping Capacity on the Effects of Telephone Follow-Up on Recovery Measures After Hysterectomy.

Background: To investigate if symptoms of depression, anxiety, and stress-coping capacity have an impact on the effect of telephone follow-up (TFU) on trajectories of six recovery measures after hysterectomy and influence the occurrence of unplanned telephone contacts (uTCs) and unplanned visits (uVs) to health care providers. Material and Methods: A post hoc nonrandomized analysis of participants enrolled in a randomized, four-armed, single-blinded, controlled multicenter intervention study comprising 487 women where the women were allocated 1:1:1:1 to one of four TFU models. The Swedish Postoperative Symptom Questionnaire (SPSQ) and two health-related quality of life questionnaires, the EuroQoL-5 dimension with three levels (EQ-5 D-3 L) and the Short-Form-Health Survey (SF-36) assessed the recovery measures. The six recovery measures consisted of the EQ-5D-3L health index, the SF-36 physical component summary (PCS) and mental component summary (MCS), and the maximum and average pain intensity, and symptom sum score obtained from the SPSQ. Psychological distress was evaluated by the psychometric forms, the Hospital Anxiety and Depression Scale and the Stress Coping Inventory. The occurrence of uTC and uV within the 6 weeks of follow-up was registered. Results: Preoperative anxiety, depression, and stress-coping capacity did not modify the effects of the TFU models on the trajectories of the recovery measures, although anxiety and depression were strongly associated with all six recovery measures. uTCs, but not uVs occurred more often in the women with anxiety. Conclusions: Preoperative anxiety, depression, and stress-coping capacity did not appear to influence the effects of TFU contacts on the recovery measures after hysterectomy. Preoperative anxiety seemed to increase the occurrence of uTC. Clinical Trials Registration: ClinicalTrials.gov (NCT01526668).

Neonatal outcomes in the surgical management of placenta accreta spectrum disorders: a retrospective single-center observational study from 468 Vietnamese pregnancies beyond 28 weeks of gestation.

BACKGROUND: Placenta accreta spectrum disorders (PASDs) increase the mortality rate for mothers and newborns over a decade. Thus, the purpose of the study is to evaluate the neonatal outcomes in emergency cesarean section (CS) and planned surgery as well as in Cesarean hysterectomy and the modified one-step conservative uterine surgery (MOSCUS). The secondary aim is to reveal the factors relating to poor neonatal outcomes. METHODS: This was a single-center retrospective study conducted between 2019 and 2020 at Tu Du Hospital, in the southern region of Vietnam. A total of 497 pregnant women involved in PASDs beyond 28 weeks of gestation were enrolled. The clinical outcomes concerning gestational age, birth weight, APGAR score, neonatal intervention, neonatal intensive care unit (NICU) admission, and NICU length of stay (LOS) were compared between emergency and planned surgery, between the Cesarean hysterectomy and the MOSCUS. The univariate and multivariable logistic regression were used to assess the adverse neonatal outcomes. RESULTS: Among 468 intraoperatively diagnosed PASD cases who underwent CS under general anesthesia, neonatal outcomes in the emergency CS (n = 65) were significantly poorer than in planned delivery (n = 403). Emergency CS increased the odds ratio (OR) for earlier gestational age, lower birthweight, lower APGAR score at 5 min, higher rate of neonatal intervention, NICU admission, and longer NICU LOS ≥ 7 days with OR, 95% confidence interval (CI) were 10.743 (5.675-20.338), 3.823 (2.197-6.651), 5.215 (2.277-11.942), 2.256 (1.318-3.861), 2.177 (1.262-3.756), 3.613 (2.052-6.363), and 2.298 (1.140-4.630), respectively, p < 0.05. Conversely, there was no statistically significant difference between the neonatal outcomes in Cesarean hysterectomy (n = 79) and the MOSCUS method (n = 217). Using the multivariable logistic regression, factors independently associated with the 5-min-APGAR score of less than 7 points were time duration from the skin incision to fetal delivery (min) and gestational age (week). One minute-decreased time duration from skin incision to fetal delivery contributed to reduce the risk of adverse neonatal outcome by 2.2% with adjusted OR, 95% CI: 0.978 (0.962-0.993), p = 0.006. Meanwhile, one week-decreased gestational age increased approximately two fold odds of the adverse neonatal outcome with adjusted OR, 95% CI: 1.983 (1.600-2.456), p < 0.0001. CONCLUSIONS: Among pregnancies with PASDs, the neonatal outcomes are worse in the emergency group compared to planned group of cesarean section. Additionally, the neonatal comorbidities in the conservative surgery using the MOSCUS method are similar to Cesarean hysterectomy. Time duration from the skin incision to fetal delivery and gestational age may be considered in PASD surgery. Further data is required to strengthen these findings.

Vaginal vault dehiscence with small bowel evisceration, bowel necrosis, and intra-abdominal haemorrhage: a case report.

Vaginal vault dehiscence with evisceration is a rare but a potentially life-threatening complication of total hysterectomy that requires prompt recognition, diagnosis, and management. The overall incidence of vaginal vault dehiscence is 0.53%. The mortality rate increases to 5.6% when bowel evisceration is present. We report a case of vaginal vault dehiscence with small bowel evisceration complicated by bowel necrosis and intra-abdominal haemorrhage in a 48-year-old woman following her first sexual intercourse 4 months after her total abdominal hysterectomy.

[Non-therapeutic hysterectomy in Mexican young females with intellectual disability: a problematized reality]. / Histerectomía no terapéutica en jóvenes mexicanas con discapacidad intelectual: una realidad problematizada.

Background: Non-therapeutic hysterectomy in girls and adolescents with intellectual disability (ID) is an acceptable practice, even when there is a lack of prescriptive ethical reason. Objectives: To determine the magnitude of the practice of hysterectomy in girls and adolescents with ID, and explore the emic factors associated with this procedure. Material and methods: Multicenter, intersectoral study with a mixed methods design. Results: The quantitative results showed that 50 of 234 reported hysterectomies corresponded to females with ID. Average age at the time of surgery was 15 ± 2.9 years. Prophylactic abdominal hysterectomy was the most common procedure, and the justifications for it were "fertility control", "menstrual hygiene management", and "risk of sexual abuse". A qualitative analysis of 15 focus groups revealed that parents' main concern was how to manage their daughters' index disease and reproductive health; they perceived menstruation positively; they expressed their fear of dying and leaving them without support, and emphasized fertility control; none of them approved hysterectomy. Conclusions: The bodies that define health policies need to create a new philosophy that avoids the reductionist approach of current biomedical model, which separates (in the health-disease process) our interdependence with other humans.

Antecedentes: La histerectomía no terapéutica en niñas y adolescentes con discapacidad intelectual (DI) es una práctica aceptable, aun cuando se carece de razón ética prescriptiva. Objetivos: Determinar la magnitud de la práctica de la histerectomía en niñas y adolescentes con DI, y explorar los factores emic asociados a esta práctica. Material y métodos: Estudio multicéntrico e intersectorial con método mixto. Resultados: Los resultados cuantitativos mostraron que 50 de 234 histerectomías reportadas correspondieron a mujeres con DI. El promedio de edad a la cirugía fue de 15 ± 2.9 años. La histerectomía abdominal profiláctica fue el procedimiento predominante y las justificaciones fueron control de fertilidad, manejo de la higiene menstrual y riesgo de abuso sexual. El análisis cualitativo de 15 grupos focales reveló que la principal preocupación de los padres fue cómo manejar la enfermedad índice y la salud reproductiva de sus hijas; percibieron positivamente la menstruación, expresaron su miedo a morir y dejarlas sin ayuda, resaltaron el control de la fertilidad y ninguno aprobó la histerectomía. Conclusiones: Los organismos que definen políticas de salud necesitan crear una nueva filosofía que evite el enfoque reduccionista del actual modelo biomédico, el cual separa (en el proceso salud-enfermedad) la interdependencia entre los seres humanos.

Clinical analysis of complete uterine rupture during pregnancy.

BACKGROUND: Uterine rupture in pregnant women can lead to serious adverse outcomes. This study aimed to explore the clinical characteristics, treatment, and prognosis of patients with complete uterine rupture. METHODS: Data from 33 cases of surgically confirmed complete uterine rupture at Chenzhou No.1 People's Hospital between January 2015 and December 2022 were analyzed retrospectively. RESULTS: In total, 31,555 pregnant women delivered in our hospital during the study period. Of these, approximately 1‰ (n = 33) had complete uterine rupture. The average gestational age at complete uterine rupture was 31+4 weeks (13+1-40+3 weeks), and the average bleeding volume was 1896.97 ml (200-6000 ml). Twenty-six patients (78.79%) had undergone more than two deliveries. Twenty-five women (75.76%) experienced uterine rupture after a cesarean section, two (6.06%) after fallopian tube surgery, one (3.03%) after laparoscopic cervical cerclage, and one (3.03%) after wedge resection of the uterine horn, and Fifteen women (45.45%) presented with uterine rupture at the original cesarean section incision scar. Thirteen patients (39.39%) were transferred to our hospital after their initial diagnosis. Seven patients (21.21%) had no obvious symptoms, and only four patients (12.12%) had typical persistent lower abdominal pain. There were 13 cases (39.39%, including eight cases ≥ 28 weeks old) of fetal death in utero and two cases (6.06%, both full term) of severe neonatal asphyxia. The rates of postpartum hemorrhage, blood transfusion, hysterectomy were 66.67%, 63.64%, and 21.21%. Maternal death occurred in one case (3.03%). CONCLUSIONS: The site of the uterine rupture was random, and was often located at the weakest point of the uterus. There is no effective means for detecting or predicting the weakest point of the uterus. Rapid recognition is key to the treatment of uterine rupture.

[Rationale for early rehabilitation of patients with uterine corpus cancer]. / Obosnovanie rannei reabilitatsii bol'nykh rakom tela matki.

OBJECTIVE: To study the dynamics of hemorheologic changes and the frequency of early complications of laparoscopic radical hysterectomy in patients with uterine corpus cancer depending on conducting rehabilitation activities in the early postoperative period. MATERIAL AND METHODS: The number of patients with uterine corpus cancer equal 49 (mean age 54.8±2.2 years), divided into 2 comparable groups, was examined: experimental group - 23 patients, who received local magnetotherapy since the first day after surgery for 5-6 days, and control group - 26 patients without physiotherapy. Comparative group included 24 healthy women. The basic rheological parameters, namely blood viscosity at high and low shear rate, hematocrit, erythrocytes' aggregation and deformability, erythrocytes and platelets electrophoretic mobility, were evaluated in all patients initially, on the 1st and 5th days after surgery and in comparison group. RESULTS: There were changes in the rheological properties of the blood before surgery in patients of both groups: increase of blood viscosity, enhancement of aggregation activity of its formed elements, decrease of erythrocytes' deformability properties. The laparoscopic radical hysterectomy was accompanied by the exacerbation of these disorders. The early magnetotherapy in patients reduced hemorheological abnormalities up to the preoperative parameters (p<0.05) for 5 days, as well as reduced the incidence of early postoperative complications by 2.4 times compared to the control group. CONCLUSION: The application of local low-frequency low-intensity magnetotherapy since the first postoperative day allows to reduce the level of postoperative hemorheological abnormalities up to the level of preoperative parameters, as well as the frequency of early postoperative complications.

Regional practice variation in hysterectomy and the implementation of less invasive surgical procedures: A register-based study in the Netherlands.

INTRODUCTION: Many women experience bleeding disorders that may have an anatomical or unexplained origin. Although hysterectomy is the most definitive and common treatment, it is highly invasive and resource-intensive. Less invasive therapies are therefore advised before hysterectomy for women with fibroids or bleeding disorders. This study has two aims related to treating bleeding disorders and uterine fibroids in the Netherlands: (1) to evaluate the regional variations in prevalence and surgical approaches; and (2) to assess the associations between regional rates of hysterectomies and less invasive surgical techniques to analyze whether hysterectomy can be replaced in routine practice. MATERIAL AND METHODS: We completed a register-based study of claims data for bleeding disorders and fibroids in women between 2016 and 2020 using data from Statistics Netherlands for case-mix adjustment. Crude and case-mix adjusted regional hysterectomy rates were examined overall and by surgical approach. Coefficients of variation were used to measure regional variation and regression analyses were used to evaluate the association between hysterectomy and less invasive procedure rates across regions. RESULTS: Overall, 14 186 and 8821 hysterectomies were performed for bleeding disorders and fibroids, respectively. Laparoscopic approaches predominated (bleeding disorders 65%, fibroids 49%), followed by vaginal (bleeding disorders 24%, fibroids 5%) and abdominal (bleeding disorders 11%, fibroids 46%) approaches. Substantial regional differences were noted in both hysterectomy rates and the surgical approaches. For bleeding disorders, regional hysterectomy rates were positively associated with endometrial ablation rates (ß = 0.11; P = 0.21) and therapeutic hysteroscopy rates (ß = 0.14; P = 0.31). For fibroids, regional hysterectomy rates were positively associated with therapeutic hysteroscopy rates (ß = 0.10; P = 0.34) and negatively associated with both embolization rates (ß = -0.08; P = 0.08) and myomectomy rates (ß = -0.03; P = 0.82). CONCLUSIONS: Regional variation exists in the rates of hysterectomy and minimally invasive techniques. The absence of a significant substitution effect provides no clear evidence that minimally invasive techniques have replaced hysterectomy in clinical practice. However, although the result was not significant, embolization could be an exception based on its stronger negative association.

Cornual adenomyosis in Essure® device users and in patients hysterectomized for other causes: A retrospective cohort study.

OBJECTIVE: To determine whether adenomyosis is present in the cornual portion of hysterectomies of symptomatic sterilization device users and in patients hysterectomized for different benign causes and who presented with pelvic pain and/or menstrual alterations. METHODS: An observational, analytical, cross-sectional, single-center, retrospective cohort study was conducted in a secondary level hospital. Cohort 1 consisted of women who had Essure® hysteroscopic sterilization devices inserted between 2009 and 2017, who developed gynecologic symptoms (pelvic pain, heavy menstrual bleeding, and/or abnormal uterine bleeding) and who underwent a hysterectomy for explantation of the devices. Cohort 2 consisted of women with the same gynecologic symptoms, who underwent a hysterectomy for other benign causes. All surgeries were performed by the gynecology team between 2018 and 2022. A descriptive and comparative analysis of sociodemographic, clinical characteristics, and pathologic findings between cohorts was made. RESULTS: In total, 96 patients were studied (cohort 1 included 34 women, cohort 2 included 62 women). Pelvic pain was found to be more frequent in the cohort of Essure users (76.47% vs. 50%, P = 0.012), with a ratio of three times higher in this group (odds ratio 3.25, 95% confidence interval 1.27-8.28). Adenomyosis was more frequently found in the Essure group, both at corporal and cornual portions, the latter being five times higher in this cohort (relative risk = 5.47; 95% confidence interval 1.17-25.64). CONCLUSIONS: The present study may be the first to describe cornual adenomyosis related to Essure devices. These devices may play a role in the development of adenomyosis and, consequently, pelvic pain. However, causality is difficult to establish.

Perioperative Venous Thromboembolism Risk in Patients Undergoing Hysterectomy for Fibroids: A US Retrospective Cohort Study.

OBJECTIVES: Venous thromboembolism (VTE) occurs in 0.4%-0.7% of benign hysterectomies. Pelvic vascular compression secondary to fibroids may elevate VTE risk. We aimed to evaluate the incidence and timing of VTE among individuals undergoing hysterectomy for fibroids and other benign indications. METHODS: Retrospective cohort study of patients who underwent a hysterectomy for fibroid and non-fibroid indications from January 2015 to December 2021. Main outcome measure was VTE consisting of pulmonary embolism or deep venous thrombosis diagnosed during 3 periods: (1) preoperative (1 year before surgery until day before surgery), (2) early postoperative (surgery date through 6 weeks after surgery), and (3) late postoperative (6 weeks to 1 year after surgery). Demographics, comorbidities, surgical characteristics, and VTE rates were compared by indication. RESULTS: A total of 263 844 individuals with fibroids and 203 183 without were identified. In total, 1.1% experienced VTE. On multivariable regression (adjusted demographic confounders and route of surgery), the presence of fibroids was associated with increased odds of preoperative (adjusted odds ratio [aOR] 1.12; 95% CI 1.03-1.22, P = 0.011) and reduced odds of late postoperative VTE (aOR 0.81; 95% CI 0.73-0.91, P < 0.001). For individuals with fibroids, uterine weight ≥250 g and undergoing laparotomy were independently associated with preoperative (aOR 1.29; 95% CI 1.09-1.52, P = 0.003 and aOR 2.32; 95% CI 2.10-2.56, P < 0.001) and early postoperative VTE (aOR 1.32; 95% CI 1.08-1.62, P = 0.006 and aOR 1.72; 95% CI 1.50-1.96, P < 0.001). CONCLUSIONS: Patients with fibroids were at increased odds of having VTE 1 year before hysterectomy. For those with fibroids, elevated uterine weight and laparotomy were associated with greater risk of preoperative and early postoperative VTEs.

Prevalence of Lower Urinary Tract Symptoms in Women Planning to Undergo Hysterectomy for Uterine Leiomyoma and Abnormal Uterine Bleeding.

Introduction: Leiomyomas are associated with lower urinary tract symptoms (LUTS), but more specific characterization of their impact on LUTS is needed. Methods: This is a retrospective cohort study of 202 participants (101 per group) who underwent hysterectomy for leiomyomas versus abnormal uterine bleeding nonclassified (AUB-N) from July 2015 to May 2019. Baseline demographics, leiomyoma characteristics, and presence of baseline LUTS were collected. The main objective was to compare the prevalence of LUTS between these two groups. Secondary objectives were to analyze the association between leiomyoma characteristics and the prevalence of LUTS. Results: There was no difference in baseline prevalence of LUTS between the hysterectomy for leiomyoma versus AUB-N groups (42.6% vs. 45.5%, p = 0.67). When examining the entire study cohort of participants, irrespective of hysterectomy indication, leiomyoma size >6 cm was associated with an increased prevalence of LUTS when compared with leiomyoma <6 cm (64.9% vs. 40.4%, p = 0.02), and specifically difficulty passing urine (p = 0.02), nocturia (p = 0.04), and urinary frequency (p = 0.04). When controlling for age, body mass index, parity, chronic pelvic pain, and diabetes, leiomyomas >6 cm remained significantly associated with the presence of LUTS (odds ratio 3.1, 95% confidence interval = 1.2-8.3) when compared with leiomyoma <6 cm. Presence of >1 leiomyoma was associated with urinary frequency (67.9% vs. 32.1%, p = 0.02) when compared with ≤1 leiomyoma. Anterior location and uterine volume were not associated with a difference in LUTS. Conclusion: LUTS are prevalent in those planning hysterectomy for leiomyoma and AUB-N. Leiomyomas >6 cm are associated with the presence of LUTS. Future studies should evaluate change in LUTS following hysterectomy for leiomyomas.

Uterine arteriovenous malformation: a case of challenges in diagnosis and management of a patient with a history of misdiagnosed hemorrhage.

Introduction: Uterine arteriovenous malformations (AVMs) are a rare cause of obstetrical hemorrhage. It can be congenital due to a defect during embryogenesis or acquired. Uterine AVMs can cause life threatening postpartum hemorrhage, and is most frequently misdiagnosed. This case highlights the diagnostic challenges posed by uterine arteriovenous malformation, a rare vascular anomaly that poses significant challenges in diagnosis and management. Case presentation: This case report details the clinical presentation, diagnostic challenges, and treatment approach for a 39-year-old woman. In the absence of a medical history indicative of pre-existing ailments, the individual in question has undergone two emergency cesarean sections as documented in her surgical history, in addition to two previous dilation and curettage D&C operations. The patient presented with heavy vaginal bleeding 6 months after a cesarean section. The patient's clinical presentation, imaging findings, and intraoperative observations collectively substantiate the diagnosis of uterine AVMs. Discussion: Women who have had uterine instrumentatio surgery, such as a cesarean section or dilatation and curettage (D&C) are more likely to develop acquired uterine AVMs. The absence of uterine artery embolism options compelled the use of alternative diagnostic methods, including contrast MRI, which successfully detected abnormal vascular lesions. The choice for hysterectomy was influenced by the patient's completion of childbearing and the presence of large vessels in proximity to critical regions. Conclusion: This case emphasizes the significance of adapting treatment plans based on local resource constraints and the need for ongoing efforts to enhance diagnostic capabilities in undeserved regions.

vNOTES Radical Hysterectomy: A New Approach To Cervical Cancer.

OBJECTIVE: To demonstrate how a radical hysterectomy with sentinel node resection for cervical cancer can be performed via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). DESIGN: Demonstration of the technique in 10 steps making use of narrated original video footage SETTING: The surgical treatment of cervical cancer is traditionally performed via one of the following techniques: Wertheim radical hysterectomy via laparotomy, Schauta radical hysterectomy vaginally, laparoscopic radical hysterectomy or robotic radical hysterectomy. The results of the LACC trial showed that minimally invasive radical hysterectomy was associated with lower rates in disease free survival and overall survival than open radical hysterectomy among women with early-stage cervical Cancer (1). For endometrial cancer a vNOTES retroperitoneal approach to sentinel node resection was first published in 2019 (2). Based on the experience with this approach and with Schauta-Stoeckel radical hysterectomy for cervical cancer (3), a new approach was developed to perform a radical hysterectomy via vNOTES whereby most of the procedure is performed retroperitoneally (4). This video article demonstrates in 10 steps how a radical hysterectomy via vNOTES is performed. INTERVENTIONS: Radical hysterectomy via vNOTES demonstrated making use of original video footage of a 57 year old woman operated for cervical adenocarcinoma 7 weeks after a LEEP cone. The steps of the procedure are: 1. Vaginal cuff creation, 2. Development of lateral retroperitoneal space and sentinel node resection, 3. Uterine artery and vein transection, 4. Hypogastric nerve dissection, 5. Development of central retroperitoneal space and rectum dissection, 6. Posterior colpotomy, 7. Parametrium dissection, 8. Bladder pillar dissection, 9. Anterior colpotomy, 10. Salpingo-oophorectomy or salpingectomy. 3 Patients were so far treated by this new technique that allowed for good hemostatic control. CONCLUSION: vNOTES enables a potentially less invasive approach to radical hysterectomy performed largely retroperitoneally and completely transvaginally leaving no visible scars. The endoscopic approach offers excellent visualization of the retroperitoneal and parametrial anatomy. This is a new approach that requires further validation and should only be performed in a research setting taking into account the current reservations about endoscopic surgery for cervical cancer resulting from the LACC trial.

Vaginal Hysterectomy at the Time of Total Colpocleisis: A Single-Center Experience.

OBJECTIVE: This study aims to evaluate the five-year experience of a single center regarding the total colpocleisis procedure. METHODS: This is a retrospective review of 24 women who underwent total colpocleisis at the study center between January 2017 and January 2023. Every participant was informed about this study, and written consent was obtained from each participant who then took Pelvic Floor Distress Inventory-20 (PFDI-20), Body Appreciation Scale-2 (BAS-2) and Decision Regret Scale (DRS) questionnaires consecutively. RESULTS: Eight patients (33.3%) underwent total colpocleisis, whereas 16 patients (66.7%) had concomitant colpocleisis and vaginal hysterectomy. The number of total colpocleisis cases did not change significantly with respect to the past years (p=0.117). The patients who underwent total colpocleisis and the patients who had concurrent colpocleisis and hysterectomy were statistically similar with respect to age, gravidity, chronic disease, blood group, American Society of Anesthesiologists classification, anesthesia type, surgery timing and preoperative and postoperative hemoglobin values (p>0.05 for all). Operative time was significantly shorter in patients who had colpocleisis alone (p=0.001). Both patient groups were also statistically similar in aspects of blood loss, transfusion need, hospital stay, postoperative complications and follow-up time as well as PFDI-20, BAS-2 and DRS scores (p>0.05 for all). Endometrial atrophy (56.3%), endometrial hyperplasia (18.8%) and adenomyosis (12.5%) were the most common histopathological findings detected in vaginal hysterectomy specimens. CONCLUSION: The combination of vaginal hysterectomy and total colpocleisis appears as a safe and efficient approach which does not contribute to the surgery-related morbidity despite the significantly longer operative time.

Iatrogenic Bladder Injury During Laparoscopic Hysterectomy: A Case Report and Discussion of Anatomic Variations.

Hysterectomy, one of the most common surgical procedures performed in women worldwide, assumes a very important role in the definitive management of diverse gynecologic conditions. This case report presents a compelling instance of an iatrogenic bladder perforation that occurred during laparoscopically assisted vaginal hysterectomy in a 47-year-old woman with a high body mass index, extensive surgical history, and postural orthostatic tachycardia syndrome. Despite considerable preoperative planning and the use of minimally invasive techniques, the occurrence of physician-induced bladder perforation highlights the significance of understanding anatomical relationships and variations. The patient's previous abdominal surgeries including two cesarean sections, appendectomy, and cholecystectomy likely contributed to scar formation and adhesions, making dissection challenging. The case report and following discussion delve into anatomical variations, as well as the diagnosis and management of iatrogenic bladder injuries. The presented case serves as a valuable addition to the literature, contributing insights into the challenges and considerations surrounding urinary tract injuries during hysterectomy. This paper aims to review current research and guide practicing obstetricians and gynecologists in the management of intraoperative bladder injuries.

Atraumatic Spontaneous Transvaginal Small Bowel Evisceration: A Rare Surgical Emergency.

Abdominal pain ranks as the predominant cause for emergency department consultations. Although rare, transvaginal evisceration of the small intestine necessitates immediate surgical intervention due to its potential to induce intestinal ischemia and peritonitis. Key risk factors include postmenopausal status, a history of gynecologic surgery, and heightened abdominal pressure. Clinical presentation typically involves pain and protrusion of intestinal contents or even abdominal viscera. Diagnosis relies on thorough clinical assessment, and treatment strategies should be tailored to each patient. Here, we describe the case of a 65-year-old female patient with a non-traumatic evisceration of the ileum, who had undergone total abdominal hysterectomy following anterior colpocele a year ago, subsequently necessitating exploratory laparotomy and repair of the vaginal ampulla.

Effect of Uterine Weight on the Surgical Outcomes of Robot-Assisted Hysterectomy in Benign Indications.

Background Uterine weight is an important factor in determining the complexity of a hysterectomy. Although greater uterine weight increases operative time and blood loss in open or laparoscopic surgery, it remains uncertain whether this applies to robot-assisted hysterectomy. This study aimed to investigate the effect of uterine weight on the surgical outcomes of robot-assisted hysterectomy. Methods We conducted a retrospective cohort study involving 872 patients who underwent robot-assisted hysterectomies at our institution between January 2019 and June 2022. Of these, 724 cases were analyzed and classified into four groups based on uterine weight: <250 g (377 patients), 250-500 g (253 patients), 500-750 g (69 patients), and ≥750 g (25 patients). We performed univariate analysis with the following endpoints: operation time, blood loss, postoperative hospital stay, complication rate, conversion to laparotomy rate, and blood transfusion rate. Results Operating time and blood loss increased significantly with greater uterine weight in the four groups (both p-values <0.01), but postoperative hospital stay and complication rate did not increase (p = 0.448, p = 0.679, respectively). None of the patients underwent conversion to laparotomy or blood transfusion. Conclusion Although the operating time for robot-assisted hysterectomy and blood loss increased with greater uterine weight, the complications and length of postoperative hospital stay were similar between groups. Robot-assisted hysterectomy is safe in cases of much uterine weight.

Cesarean hysterectomy for placenta accreta spectrum: 3-2-1 approach.

Given the high risk of complications associated with cesarean hysterectomy for placenta accreta spectrum (PAS), any surgical approach and technique can yield utility in reducing the surgical morbidity. Here, we propose the 3-2-1 approach as a schema to be implemented in the proper setting for the surgical management of a PAS cesarean hysterectomy. The 3-2-1 approach begins with the surgical dissection of three anatomical landmarks that ultimately facilitate a safe surgical site for the ligation and transection of the uterine vessels. First-step is identification of the three anatomical landmarks which are (i) posterior lower uterine segment peritoneum de-serosalization, (ii) identification of the ureters laterally, and (iii) anterior bladder dissection. Posterior-to-anterior progression avoids encountering dense adhesions and hypervascularity in the anterior lower uterine segment early in the surgery. Further, allows better mobilization of the uterus to identify the anatomical landmarks laterally and anteriorly. Second-step is to deploy the 2-hand technique where the surgeon places one hand anteriorly and the other hand posteriorly in the lower uterine segment below the placental bed. The surgeon brings both hands together with flexed fingers perpendicular to the uterine tissue and gently elevates the uterus and placenta out of the pelvis and ensures safe anatomical distance to surrounding structures. Third-step is the consideration of a supracervical hysterectomy. In summary, this 3-2-1 approach to reflect the anatomy of enlarged lower uterine segment in PAS is a stepwise schema that can aid surgeons in the completion of a cesarean hysterectomy, with the goal to improve surgical outcomes.

Cesarean hysterectomy for placenta accreta spectrum: Surgeon specialty-specific assessment.

OBJECTIVE: To assess (i) clinical and pregnancy characteristics, (ii) patterns of surgical procedures, and (iii) surgical morbidity associated with cesarean hysterectomy for placenta accreta spectrum based on the specialty of the attending surgeon. METHODS: The Premier Healthcare Database was queried retrospectively to study patients with placenta accreta spectrum who underwent cesarean delivery and concurrent hysterectomy from 2016 to 2020. Surgical morbidity was assessed with propensity score inverse probability of treatment weighting based on surgeon specialty for hysterectomy: general obstetrician-gynecologists, maternal-fetal medicine specialists, and gynecologic oncologists. RESULTS: A total of 2240 cesarean hysterectomies were studies. The most common surgeon type was general obstetrician-gynecologist (n = 1534, 68.5%), followed by gynecologic oncologist (n = 532, 23.8%) and maternal-fetal medicine specialist (n = 174, 7.8%). Patients in the gynecologic oncologist group had the highest rate of placenta increta or percreta, followed by the maternal-fetal medicine specialist and general obstetrician-gynecologist groups (43.4%, 39.6%, and 30.6%, P < .001). In a propensity score-weighted model, measured surgical morbidity was similar across the three subspecialty groups, including hemorrhage / blood transfusion (59.4-63.7%), bladder injury (18.3-24.0%), ureteral injury (2.2-4.3%), shock (8.6-10.5%), and coagulopathy (3.3-7.4%) (all, P > .05). Among the cesarean hysterectomy performed by gynecologic oncologist, hemorrhage / transfusion rates remained substantial despite additional surgical procedures: tranexamic acid / ureteral stent (60.4%), tranexamic acid / endo-arterial procedure (76.2%), ureteral stent / endo-arterial procedure (51.6%), and all three procedures (55.4%). Tranexamic acid administration with ureteral stent placement was associated with decreased bladder injury (12.8% vs 23.8-32.2%, P < .001). CONCLUSION: These data suggest that patient characteristics and surgical procedures related to cesarean hysterectomy for placenta accreta spectrum differ based on surgeon specialty. Gynecologic oncologists appear to manage more severe forms of placenta accreta spectrum. Regardless of surgeon's specialty, surgical morbidity of cesarean hysterectomy for placenta accreta spectrum is significant.

Incidental actinomycosis in a 44-year-old female during total abdominal hysterectomy for abnormal uterine bleeding: A case report.

Actinomycosis, a rare chronic bacterial infection caused by Actinomyces species, presents diagnostic challenges due to diverse clinical presentations. This report presents a case of peritoneal actinomycosis incidentally discovered during a total abdominal hysterectomy in a 44-year-old female with refractory abnormal uterine bleeding and a history of long-term intrauterine contraceptive device use. The patient presented with persistent abnormal uterine bleeding despite conservative management. Intraoperative findings during total abdominal hysterectomy revealed peritoneal involvement, prompting histopathological evaluation confirming actinomycosis. This case highlights diagnostic complexities associated with actinomycosis, emphasizing the significance of histopathological confirmation. Postoperative management with antibiotics demonstrated favorable outcomes, supporting their efficacy in treating actinomycosis. The case underscores the importance of considering uncommon infections in pelvic pathology, particularly in patients with prolonged intrauterine contraceptive device usage. It prompts further exploration of actinomycosis in relation to intrauterine contraceptive device use and highlights the need for timely intervention and histopathological confirmation for optimal patient care.

Conservative management or cesarean hysterectomy for placenta accreta spectrum in middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Cesarean hysterectomy is a dominant and effective approach during delivery in patients with placenta accreta spectrum (PAS). However, as hysterectomy results in a loss of fertility, conservative management is an alternative approach. However, management selection may be affected by a country's overall economic level. Thus the preferred treatment for PAS generates controversy in middle-income countries. OBJECTIVES: We aimed to compare conservative management and cesarean hysterectomy for managing PAS in middle-income countries. SEARCH STRATEGY: China National Knowledge Infrastructure, Wanfang Med Online Databases, Cochrane Library, Ovid MEDLINE, PubMed, Web of Science, EMBASE, clinicaltrials.gov, and Scopus were searched from inception through to October 1, 2022. SELECTION CRITERIA: We included studies that evaluated at least one complication comparing conservative management and hysterectomy. All cases were diagnosed with PAS prenatally and intraoperatively. DATA COLLECTION AND ANALYSIS: The primary outcomes were blood loss, adjacent organ damage, and the incidence of hysterectomy. Descriptive analyses were conducted for studies that did not meet the meta-analysis criteria. A fixed-effects model was used for studies without heterogeneity and a random-effects model was used for studies with statistical heterogeneity. MAIN RESULTS: In all, 11 observational studies were included, with 975 and 625 patients who underwent conservative management and cesarean hysterectomy, respectively. Conservative management was significantly associated with decreased blood loss and lower risks of adjacent organ injury and hysterectomy. Conservative management significantly reduced blood transfusions, hospitalization duration, operative time, intensive care unit admission rates, and infections. There were no significant differences in the risks of coagulopathy, thromboembolism, or reoperation. CONCLUSION: Given short-term complications and future fertility preferences for patients, conservative management appears to effectively manage PAS in middle-income countries. Owing to low levels of evidence, high heterogeneity and insufficient long-term follow-up data, further detailed studies are warranted.