Ureteric injuries during hysterectomy-A Norwegian retrospective study of occurrence and claims for compensation over an 11-year period.

INTRODUCTION: Ureteric injury is a rare but serious, iatrogenic complication of hysterectomy. The risk depends on indication for surgery, predisposing risk factors, and peroperative conditions. Our aims were to evaluate and learn from compensation claims to The Norwegian System of Patient Injury Compensation (NPE) for ureteric injury occurring during hysterectomies to predict risk factors, time of identification, symptoms, and consequences, and to relate these cases to injuries registered in The Norwegian Patient Registry. MATERIAL AND METHODS: A retrospective study of ureteric injuries occurring during hysterectomies, reported to NPE and the Norwegian Patient Registry from 2009 through 2019. RESULTS: During the study period, 53 096 hysterectomies were registered in The Norwegian Patient Registry, of which ureteric injury was documented in 643 (1.2%). More ureteric injuries were registered in large hospital trusts than in small trusts (1.3% vs. 0.7%, p < 0.05). NPE received 69 claims due to ureteric injury occurring during hysterectomy, comprising 11% of all injuries in the study period. Compensation was approved for 15%. Women who claimed compensation were younger (48.1 ± 8.9 years vs. 55.1 ± 13.6 years, p < 0.01), more likely to have had a benign diagnosis (89.9% vs. 52.1%, p < 0.01), and more likely to have had the ureteric injury recognized after discharge (58.0% vs. 33.0%, p < 0.001) compared with non-complainants. Identification of the ureters during the hysterectomy was documented in 30% of the NPE patient files. Additional information for the NPE cases included the following. The most common symptoms of unidentified injury were pain (77%), fever (12%), urinary leakage (13%), and anuria (8%). Re-operation was necessary in 77% of the cases, and 10% of the women lost one kidney. Long-term consequences after repair, such as loss of a kidney or persistent pain, were seen in 17%. No women died because of the injury. CONCLUSIONS: The incidence of ureteric injury occurring during hysterectomy in Norway was 1.2%; 11% involved a claim for compensation, and 15% of these had their case approved. Most ureteric injuries were not recognized during the hysterectomy. Documentation of peroperative identification of the ureters during hysterectomy was often missing. Vigilance to pain as a postoperative symptom of peroperative unrecognized ureteric injury may result in earlier diagnosis and treatment.

Exploring the impact of indication on variation in rates of intrapartum caesarean section in six Palestinian hospitals: a prospective cohort study.

BACKGROUND: Caesarean section rates are rising globally. No specific caesarian section rate at either country-level or hospital-level was recommended. In Palestinian government hospitals, nearly one-fourth of all births were caesarean sections, ranging from 14.5 to 35.6%. Our aim was to assess whether variation in odds for intrapartum caesarean section in six Palestinian government hospitals can be explained by differences in indications. METHODS: Data on maternal and fetal health were collected prospectively for all women scheduled for vaginal delivery during the period from 1st March 2015 to 30th November 2016 in six government hospitals in Palestine. Comparisons of proportions in sociodemographic, antenatal obstetric characteristics and indications by the hospital were tested by χ2 test and differences in means by one-way ANOVA analysis. The odds for intrapartum caesarean section were estimated by logistic regression. The amount of explained variance was estimated by Nagelkerke R square. RESULTS: Out of 51,041 women, 4724 (9.3%) underwent intrapartum caesarean section. The prevalence of intrapartum caesarean section varied across hospitals; from 7.6 to 22.1% in nulliparous, and from 5.8 to 14.1% among parous women. The most common indications were fetal distress and failure to progress in nulliparous, and previous caesarean section with an additional obstetric indication among parous women. Adjusted ORs for intrapartum caesarean section among nulliparous women ranged from 0.42 (95% CI 0.31 to 0.57) to 2.41 (95% CI 1.70 to 3.40) compared to the reference hospital, and from 0.50 (95% CI 0.40-0.63) to 2.07 (95% CI 1.61 to 2.67) among parous women. Indications explained 58 and 66% of the variation in intrapartum caesarean section among nulliparous and parous women, respectively. CONCLUSION: The differences in odds for intrapartum caesarean section among hospitals could not be fully explained by differences in indications. Further investigations on provider related factors as well as maternal and fetal outcomes in different hospitals are necessary.

Tapentadol versus oxycodone analgesia and side effects after laparoscopic hysterectomy: A randomised controlled trial.

BACKGROUND: Tapentadol is an opioid, which acts as a µ-opioid receptor agonist and inhibits noradrenaline reuptake in the central nervous system. This dual mechanism of action results in synergistic analgesic effects and potentially less side effects. This has been shown in treatment of chronic pain but postoperative studies are sparse. OBJECTIVES: The main aim was to compare the analgesic effect of tapentadol with oxycodone after laparoscopic hysterectomy. Opioid side effects were recorded as secondary outcomes. DESIGN: Randomised, blinded trial. SETTING: Single-centre, Oslo University Hospital, Norway, December 2017 to February 2019. PATIENTS: Eighty-six opioid-naïve American Society of Anesthesiologists physical status 1 to 3 women undergoing laparoscopic hysterectomy for nonmalignant conditions. INTERVENTION: The patients received either oral tapentadol (group T) or oxycodone (group O) as part of multimodal pain treatment. Extended-release study medicine was administered 1 h preoperatively and after 12 h. Immediate-release study medicine was used as rescue analgesia. MAIN OUTCOME MEASURES: Pain scores, opioid consumption and opioid-induced side effects were evaluated during the first 24 h after surgery. RESULTS: The groups scored similarly for pain at rest using a numerical rating scale (NRS) 1 h postoperatively (group T 4.4, 95% CI, 3.8 to 5.0, group O 4.6, 95% CI, 3.8 to 5.3). No statistically significant differences were found between the groups for NRS at rest or while coughing during the 24-h follow-up period (P = 0.857 and P = 0.973). Mean dose of oral rescue medicine was similar for the groups (P = 0.914). Group T had significantly lower odds for nausea at 2 and 3 h postoperatively (P = 0.040, P = 0.020) and less need for antiemetics than group O. No differences were found for respiratory depression, vomiting, dizziness, pruritus, headache or sedation. CONCLUSION: We found tapentadol to be similar in analgesic efficacy to oxycodone during the first 24 h after hysterectomy, but with significantly less nausea. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03314792.

Claims for compensation from women with cervical cancer in Norway-A retrospective, descriptive study of a 12-year period.

INTRODUCTION: In Norway, all patient-reported claims for compensation are evaluated by The Norwegian System of Patient Injury Compensation (NPE). The number of claims from women with cervical cancer is rising, and the approval rate is high. Our aim was to study claims for compensation from women with cervical cancer to identify the type of failures, when, during the time-course of treatment, the medical failures occurred, and the consequences of the failures. MATERIAL AND METHODS: A retrospective, descriptive study of claims for compensation to NPE from cervical cancer patients during a 12-year period, from 2007 through 2018. We used anonymized medical expert statements and summaries of NPE cases. RESULTS: In all, 161 women claimed compensation for alleged medical failure related to cervical cancer. Compensation was approved for 100 (62%) women. Mean age at the time of alleged failure was 37.5 years (SD ±9.9). The main reasons why women sought medical attention were routine cervical screening (56%), or vaginal bleeding or discharge (30%). In approved cases, incorrect evaluation of cytology and histology was the cause of most failures (72%). Mean delay of cervical cancer diagnosis for approved cases was 28 months (SD ±22). Treatment not in accordance with guidelines was the cause of failure in 2% of the cases, and failure during follow up was the cause of failure in 12%. Consequences of the failures were as follows: worsening of cancer prognosis (89%), treatment-induced adverse effects, such as loss of fertility (43%) and/or loss of ovarian function in premenopausal women (50%), and permanent injury after chemo-radiation (27%). Seven women (7%) died, most probably as a consequence of the failure. CONCLUSIONS: The main cause of medical failure in women with cervical cancer was incorrect pathological diagnosis. The main consequences of failures were worsening of cancer prognosis and treatment-induced adverse effects. Increased focus on the quality of pathological examinations, and better routines in all parts of the cervical examinations might improve patient safety for women in risk of cervical cancer.

Noninvasive Diagnosis of Adenomyosis: A Structured Review and Meta-analysis of Diagnostic Accuracy in Imaging.

OBJECTIVE: To conduct a systematic review and meta-analysis to evaluate imaging methods used to diagnose adenomyosis. DATA SOURCES: A thorough search was completed through the Cochrane Central Register of Controlled Trials, EMBASE, and PubMed or MEDLINE databases from January 2000 to June 2019. METHODS OF STUDY SELECTION: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Quality Assessment of Diagnostic Accuracy Studies 2 tool, studies reporting the diagnostic accuracy of an imaging method and histopathology as a reference standard were selected and prospectively registered in the International Prospective Register of Systematic Reviews. Statistical analysis was performed using the R-package Meta-Analysis of Diagnostic Accuracy. TABULATION, INTEGRATION, AND RESULTS: Of the 1168 records identified, 10 studies were included in the meta-analysis, and these included 827 patients undergoing 2- or 3-dimensional transvaginal ultrasound (TVUS) and 317 patients undergoing magnetic resonance imaging (MRI). The risk of bias was low or unclear for all Quality Assessment of Diagnostic Accuracy Studies domains. The overall prevalence of adenomyosis was 40%. Overall MRI, 2-dimensional TVUS, 3-dimensional TVUS, and TVUS had the following aggregated diagnostic qualities (95% confidence interval): sensitivity of 78% (70%-84%), 74% (68%-79%), 84% (77%-89%), 78% (73%-82%); specificity of 88% (83%-92%), 76% (71%-79%), 84% (77%-89%), 78% (74%-81%); positive likelihood ratio of 6.8 (4.5%-10%), 3 (2.5%-3.7%), 5.2 (3.6%-7.4%), 3.5 (3%-4.2%); negative likelihood ratio of 0.25 (0.18%-0.35%), 0.34 (0.27%-0.43%), 0.19 (0.13%-0.28%), 0.28 (0.23%-0.34%); and pooled area under the operator curve of 0.77, 0.7, 0.83, 0.73, respectively. The pooled area under the operator curve for all modalities was not significantly different (all: p ≥.4). CONCLUSION: As a result of the systemic review and meta-analysis, we identified TVUS and MRI as good and comparable noninvasive imaging methods for diagnosing adenomyosis, leading us to recommend TVUS as the first-line diagnostic imaging method and MRI as a second-line method, if TVUS is inconclusive.

Hysterectomy in Norway 2008-18. / Hysterektomi i Norge 2008­18.

BACKGROUND: Hysterectomy is a common gynaecological procedure. No Norwegian guidelines for the choice of hysterectomy surgical method exist, but international guidelines recommend minimally invasive surgery. The objective of this study was to investigate the kinds of surgical methods that were used for hysterectomies in the period 2008-18. Furthermore, we wished to identify the scope of robot-assisted hysterectomies and to find out whether salpingectomies are undertaken on a benign indication in Norway. MATERIAL AND METHOD: The study is based on data from the Norwegian Patient Registry. Relevant variables for all gynaecological hysterectomies in Norway in the period 2008-18 were collected at the individual level. RESULTS: During the study period, 53 178 hysterectomies were registered in the Norwegian Patient Registry. The proportion of hysterectomies that were performed with minimally invasive techniques increased from 41 % to 73 % during the study period. Robot-assisted hysterectomies accounted for 15 % of the total in 2018. The number of concomitant salpingectomies also increased during the period, and were performed in more than half of all hysterectomies undertaken on a benign indication. INTERPRETATION: Norwegian gynaecologists largely follow international guidelines and recommendations regarding minimally invasive hysterectomy and salpingectomy. Although the total proportion of minimally invasive hysterectomies is now relatively high, there are considerable variations between the different health trusts.

Diagnosing adenomyosis with MRI: a prospective study revisiting the junctional zone thickness cutoff of 12 mm as a diagnostic marker.

OBJECTIVES: To assess the diagnostic accuracy of a junctional zone (JZ) thickness of ≥ 12 mm and morphological features of the JZ in MRI in diagnosing adenomyosis in a premenopausal study population. METHODS: This single-center, prospective observational study consecutively enrolled 93 premenopausal women suffering from a benign gynecological condition, from September 2014 to August 2016. Institutional review board approval and written consent were obtained. All participants underwent MRI and hysterectomy with a histopathological examination. MR images were evaluated in a blinded fashion by two independent readers. The maximum junctional zone thickness (JZmax), presence of JZmax ≥ 12 mm, and any irregular appearance of the JZ (defined as irregular outer or inner borders, focal thickening, presence of high-intensity signal foci, or fingerlike indentations at the inner border) were documented, and the diagnostic performance was evaluated with the AUC, chi-square test, and multiple regression. RESULTS: Adenomyosis was histopathologically confirmed in 57 (61%) of the women. JZmax was not positively correlated with adenomyosis diagnosis (AUC = 0.57, p = 0.26) and did not differ significantly between those with and without adenomyosis (10.3 vs 10.1 mm, p = 0.88), nor was a cutoff of JZmax ≥ 12 mm (n = 30/57 (53%) vs n = 16/36 (44%), p = 0.29). The presence of an irregular JZ showed the best association with adenomyosis among the evaluated signs (sensitivity 74% (95% CI, 60, 85); specificity 83% (95% CI, 67, 94) (p < 0.001)). CONCLUSIONS: JZmax was not correlated with adenomyosis in the present premenopausal study population, but direct signs of adenomyosis such as irregularities of the JZ provided a good diagnostic accuracy. KEY POINTS: • Measuring the junctional zone thickness is of limited value for diagnosing adenomyosis with MRI and should not be used for diagnosing adenomyosis in premenopausal women with moderate disease severity. • An irregular appearance of the junctional zone, the presence of myometrial cysts, and adenomyoma appear to provide the highest specificity for diagnosing adenomyosis. • A consensus for the definition and reading of the junctional zone is needed.

Approved claims for compensation from gynecological patients in Norway-What characterizes the cases? A 14-year nationwide study.

INTRODUCTION: The Norwegian System of Patient Injury Compensation (NPE) evaluates all patient-reported claims in Norway. Our aim was to study the cases from gynecological patients approved by NPE in order to identify the main reasons for the injuries, the consequences of the treatment failure for the women, and the time course when the treatment failure occurred. MATERIAL AND METHODS: A retrospective, descriptive study of approved gynecological compensation claims during a 14-year period, based on patient files from NPE. RESULTS: In all, 1454 women claimed compensation for injury related to gynecological treatment in Norway from 2000 to 2013. Compensation was approved for 438 (30.1%) women. Eleven women declined participation in the study and 16 cases were excluded, leaving 411 cases for further analyses. Consent to participate was given by 211 (51.3%) women, who gave full access to all their NPE files. Anonymized resumes and expert statements were used for the 138 (33.6%) women who did not respond and the 62 (15.1%) women who were deceased. Guidelines or good clinical practice were not followed in 40.5% of the cases. The most common reasons for injury were surgical complications (67.6%), delayed (22.4%) and incorrect (17.0%) diagnoses, and failure of communication (11.7%). The main consequences of injuries were need for extensive treatment (64.2%), permanent injury (55.2%) and impaired physical ability (41.9%). Worsening of cancer prognosis occurred in 58 women (14.1%) and death due to treatment failure in 29 (7.1%) women. Most failures occurred during the treatment period (75.2%). CONCLUSIONS: We found that the main reason for injuries in gynecological patients was non-adherence to guidelines or good clinical practice. Surgery-related injuries were most common. Increased focus on adherence to guidelines and surgical skills might improve patient safety for gynecological patients in Norway.

In Vivo Adenomyosis Tissue Sampling Using a Transvaginal Ultrasound-guided Core Biopsy Technique for Research Purposes: Safety, Feasibility, and Effectiveness.

STUDY OBJECTIVE: To determine if it is possible and safe to obtain adenomyosis tissue in vivo without removing the uterus in order to use it for further molecular investigations of adenomyosis, which would allow investigating the pathogenesis of the disease. DESIGN: A prospective cohort study. SETTING: A university hospital. PATIENTS: Eighty-one premenopausal women scheduled for a hysterectomy because of various benign indications were included. INTERVENTIONS: Ultrasound-guided, transvaginal uterine core biopsy samples were obtained, and the required time was registered. Any trauma to the pelvic organs, blood loss, and other complications were documented during the subsequent hysterectomy. Two biopsy samples were analyzed histopathologically to confirm the presence of adenomyosis, and another 2 were snap frozen using liquid nitrogen for use in further research. Laser microscopic dissection and RNA extraction were performed on the collected samples. MEASUREMENTS AND MAIN RESULTS: Biopsy specimens could be obtained in 80 (99%) of the 81 cases. There was no visible trace of the biopsy retrieval in 20 women (25%), perforation of uterine serosa or peritoneum was present in 56 (70%), and ongoing minor bleeding occurred in 4 (5%). The median amount of bleeding was 2 mL (range, 0-200 mL). No serious complications were observed. The procedure took 6.1 ± 1.9 minutes (mean ± standard deviation). Adenomyosis tissue was obtained in 10 (22%) of the 45 cases with adenomyosis. The inner myometrium with the junctional zone was accessible in all cases. It was possible to produce frozen sections, extract RNA, and dissect single adenomyosis glands with laser microscopic dissection. CONCLUSIONS: No serious complications caused by the uterine biopsies were observed. This technique opens up the possibility of investigating early stages of adenomyosis and the inner myometrium containing the junctional zone independent of hysterectomy specimens.

Uterine leiomyosarcoma - incidence, treatment, and the impact of morcellation. A nationwide cohort study.

INTRODUCTION: The risk of morcellation of occult uterine leiomyosarcomas (LMS) during laparoscopic procedures has been under scrutiny over recent years. The objective of this study was to assess the operative treatment performed in women with uterine LMS in Norway in 2000-2012, including the number of morcellated LMS. MATERIAL AND METHODS: Retrospective nationwide cohort study. The study participants were all women with histopathologically verified uterine LMS in Norway during 2000-2012. The data were collected from the Cancer Registry of Norway, National Patient Registry and medical records. RESULTS: There were 212 women diagnosed with uterine LMS in Norway in 2000-2012. Mean age at time of diagnosis was 58.1 years (SD ± 12.5). The most frequent symptom in women suffering from LMS was abnormal uterine bleeding [110/212 (51.9%)]. LMS was histopathologically verified in 49/212 (23.1%) preoperatively. In 48/212 (22.6%), a malignant condition was suspected and they were treated accordingly. In 115/212 (54.2%), malignancy was not suspected at time of surgery and the women were treated according to the treatment protocol for fibroids. In only four patients was tissue retrieval by power morcellation conducted, accounting for 1.9% of all LMS cases. CONCLUSIONS: In more than 50% of women suffering from LMS, a malignant diagnosis was not confirmed or suspected prior to surgery. In our material, power morcellation of LMS has not lead to reduced survival. We suggest that power morcellators may be used in surgical treatment of selected cases of premenopausal women with symptomatic, presumed benign uterine leiomyomas.

Preoperative evaluation in women with uterine leiomyosarcoma. A nationwide cohort study.

INTRODUCTION: The goal of this study was to assess the sensitivity of different preoperative diagnostic tools used in women with uterine leiomyosarcomas. MATERIAL AND METHODS: Retrospective cohort study of all women with verified uterine leiomyosarcoma in Norway in the period 2000 to 2012. Data were collected from the Cancer Registry of Norway and medical records. RESULTS: There were 212 women diagnosed with uterine leiomyosarcoma in the 13-year period. Histopathological examinations by fractional curettage or endometrial biopsies verified malignancy in 55/142 (38.7%). MRI suggested malignancy in 45/55 (81%) of the examinations. CT evaluations indicated suspected malignancy in 64/107 women (59.8%). Biomarkers had low sensitivity for leiomyosarcoma, but suggested more advanced stage disease when high values were detected. Stage IV disease was present in 53.1% versus 25.5% (p = 0.01) of women with CA 125 values above 35 kU/L, compared with women with normal CA 125 values. In 115/212 (54.2%), leiomyosarcoma was only diagnosed postoperatively by histopathological examination of the removed specimen. CONCLUSIONS: Preoperative diagnostic modalities appear to have low sensitivity for differentiating leiomyosarcoma from fibroids. In Norway, approximately 54% of uterine leiomyosarcoma are unidentified before surgery. MRI evaluation was the imaging modality with the greatest sensitivity in identifying leiomyosarcoma preoperatively.

Risk of morcellation of uterine leiomyosarcomas in laparoscopic supracervical hysterectomy and laparoscopic myomectomy, a retrospective trial including 4791 women.

STUDY OBJECTIVE: To evaluate the incidence of uterine leiomyosarcomas (LMSs). To identify the risk of morcellating LMS in a gynecological department that offers laparoscopic supracervical hysterectomy (LSH) and laparoscopic myomectomy as primary surgical treatments. DESIGN: A retrospective trial. DESIGN CLASSIFICATION: Canadian Task Force Classification III. SETTING: Norwegian university teaching hospital. PATIENTS: Women diagnosed with uterine LMS and the total population of women who were referred for surgical treatment of uterine fibroids from January 1, 2000 to December 31, 2013. INTERVENTIONS: Surgical treatment of fibroids, including LSH, abdominal supracervical hysterectomy, total laparoscopic hysterectomy, total abdominal hysterectomy, laparoscopic myomectomy, and hysteroscopic resection of fibroids. MEASUREMENTS AND MAIN RESULTS: A total of 4791 women were included in this trial; 1957 laparoscopic procedures were performed, and a morcellator was used in 1846 of the procedures. Twenty-six women were diagnosed with uterine LMS specimens after surgery. The mean ± SD age of women with LMS was 61.2 ± 12.3 years, and the mean ± SD of the tumor size at time of diagnosis was 90.9 ± 45.4 mm. Of these 26 women, 6 were diagnosed with uterine LMS by endometrial biopsy before surgical treatment, and 14 women were treated by open hysterectomy and bilateral salpingo-oophorectomy due to a clinical preoperative suspicion of a malignant condition. Consequently, 6 women with uterine LMS were treated according to the protocol for anticipated benign fibroids. Five of these women underwent laparotomy due to tumor size. LSH was performed in 1 woman, and a morcellator was used for tissue extraction. The incidence of uterine LMS in the population of women referred for anticipated benign fibroids was 0.0054 (1 in 183 women). The rate of unintended morcellation of a LMS at our department between January 1, 2000 and December 31, 2013 was 0.0002 (1 in 4791 women). CONCLUSION: The incidence of uterine LMS was comparable with the incidence reported in the literature. The risk of unintended morcellation of uterine LMS after a preoperative selection of women with fibroids appears to be very low.

Assessment of periodic blood loss: interindividual and intraindividual variations of pictorial blood loss assessment chart registrations.

STUDY OBJECTIVE: To explore the interindividual and intraindividual variation of Pictorial Blood Loss Assessment Chart (PBAC) registrations of subjective perception of minimal, normal, and heavy menstrual bleeding in women using their usual sanitary protection. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University tertiary hospital. PATIENTS: Women who had participated in 4 previously published prospective studies using PBAC as the outcome measure. INTERVENTIONS: Patients underwent hysteroscopic removal of polyps, laparoscopic occlusion of uterine vessels, or uterine artery embolization, and control subjects received no treatment. MEASUREMENTS AND MAIN RESULTS: PBAC scores, hemoglobin concentration, and subjective assessment of periodic blood loss were recorded in 429 women during 1049 menstrual cycles. The median PBAC values in groups of women who assessed their bleeding as light, normal, and heavy were 45.0, 116.0, and 254.5, respectively (p < .001). Sensitivity and specificity for specific PBAC cutoff points were calculated using a receiver operating characteristic curve. The maximum sensitivity for assessment of heavy periodic blood loss (78.5) was reached at a PBAC score of 160. The corresponding specificity was 75.8. At PBAC values below 130, 90% of the women reported normal blood loss, and 91% had hemoglobin values >12.0 g/dL. The reliability of repeated PBAC scores for individual measures was assessed via calculation of the intraclass correlation coefficient, which for repeated PBAC measurements was 0.86 (95% confidence interval, 0.80-0.90) for average measures. CONCLUSION: The interindividual variation was high, and the intraindividual variation was low. A low PBAC score may be used to define treatment end points for clinical use or in trials.

Pelvic pain and patient satisfaction after laparoscopic supracervical hysterectomy: prospective trial.

STUDY OBJECTIVE: To evaluate the occurrence and intensity of cyclic pelvic pain and patient satisfaction after laparoscopic supracervical hysterectomy and to explore the effect of the procedure on pelvic pain relief in women with perioperative detection of endometriosis and in women with histologic confirmation of adenomyosis. DESIGN: Prospective observational study with 12-month follow-up after laparoscopic supracervical hysterectomy (Canadian Task Force classification II-2). SETTING: University teaching hospital in Norway. PATIENTS: One hundred thirteen premenopausal women with preoperative cyclic pelvic pain treated via laparoscopic supracervical hysterectomy. INTERVENTIONS: Study participants underwent laparoscopic supracervical hysterectomy and were followed up at the outpatient clinic at 12 months after the procedure. MEASUREMENTS AND MAIN RESULTS: The main outcomes were occurrence, intensity, and reduction of cyclic pelvic pain and patient satisfaction measured using an ordinal and a visual analog scale at 12 months after the procedure. Of the 113 women included in the study, 8 were lost to follow-up. Consequently, 105 women (92.9%) were followed up at 12 months after surgery. All women had cyclic pelvic pain preoperatively, but only 34 (32.4%) experienced this pain at 12 months after the procedure. The intensity of pelvic pain was reduced from a mean (SD) of 5.5 (2.4) preoperatively to 0.7 (1.5) at 12 months after the procedure on a visual analog scale of 0 to 10 (p < .01). Endometriosis was diagnosed perioperatively in 14 women (12.4 %), and adenomyosis was confirmed at histologic analysis in 19 (18.1%). In women with perioperative detection of endometriosis or histologic confirmation of adenomyosis, there were no significant differences in main outcomes at 12 months after laparoscopic supracervical hysterectomy when compared with women without these diagnoses. CONCLUSION: Laparoscopic supracervical hysterectomy is associated with high patient satisfaction and reduces cyclic pelvic pain to a minimum by 12 months after the procedure.

Laparoscopic supracervical hysterectomy performed with and without excision of the endocervix: a randomized controlled trial.

STUDY OBJECTIVE: To compare the occurrence of vaginal bleeding and patient satisfaction 12 months after laparoscopic supracervical hysterectomy performed with and without excision of the endocervix. DESIGN: A prospective, randomized, controlled trial. DESIGN CLASSIFICATION: Canadian Task Force Classification I. SETTING: Norwegian university teaching hospital. PATIENTS: One hundred forty consecutive premenopausal women referred for hysterectomy on the basis of a benign condition. INTERVENTIONS: The study participants were randomized to standard laparoscopic supracervical hysterectomy (n = 70) or laparoscopic supracervical hysterectomy with excision of the endocervix in a reverse cone pattern (n = 70). MEASUREMENTS AND MAIN RESULTS: The main outcome measures were the occurrence of vaginal bleeding and patient satisfaction 12 months after the procedure. One hundred thirty women (92.3%) were followed up according to the study protocol. In total, 43 women (33.1%) reported bleeding episodes during the first 12 months after the laparoscopic supracervical hysterectomy; 22 (16.9 %) of these women had cyclic bleeding. All reported bleeding episodes were minimal. Patient satisfaction after the hysterectomy was very high with a mean visual analog score (on a scale of 0-10) of 9.3 (standard deviation = 1.4). There were no significant differences between the 2 treatment groups regarding the main outcomes 12 months after the procedure. CONCLUSION: The patient satisfaction after laparoscopic supracervical hysterectomy is very high. Episodes of minimal vaginal bleeding after the procedure are relatively common, but such bleeding does not affect patient satisfaction. Removal of the endocervix by reverse conization during laparoscopic supracervical hysterectomy appears to have no effect in terms of reduced bleeding or improved patient satisfaction.

Treatment of endometrial polyps: a systematic review.

BACKGROUND: Transcervical resection of endometrial polyps is usually performed in order to exclude atypic and/or malignant endometrial changes, to relieve abnormal uterine bleeding or to improve infertility. OBJECTIVE: To systematically explore the rationale of transcervical polyp resection. SEARCH STRATEGY: Electronic searches of MEDLINE, EMBASE and The Cochrane Library. SELECTION CRITERIA: Studies reporting the prevalence of premalignant and/or malignant tissue changes within endometrial polyps, as well as outcomes of endometrial polyp removal in terms of symptom relief and improved fertility were included. MAIN RESULTS: 46 studies met the criteria for inclusion (malignancy: 20 studies including 9,266 women, symptom relief: 15 studies including 1,034 women, infertility: 11 studies including 935 women). Most studies were uncontrolled retrospective case series. Only two randomized controlled trials were identified. The prevalence of premalignant and malignant tissue changes within endometrial polyps varied in the included studies, 0.2-23.8% and 0-12.9%, respectively. Postmenopausal symptomatic women appeared to have the highest risk of premalignant and malignant tissue changes. The effect of polypectomy on periodic blood loss appeared to be questionable, but all studies measuring the effect of polypectomy by general terms such as improved/not improved reported a favorable outcome (75-100% success rate). Polypectomy appears to have a favorable outcome in infertile women. CONCLUSIONS: The evidence which substantiates the removal of endometrial polyps is limited, and future research evaluating the outcome of this common procedure is required. Based on the available evidence, however, we provide recommendations for treatment of women with endometrial polyps.

Transvaginal Sonographic Imaging and Associated Techniques for Diagnosis of Ovarian, Deep Endometriosis, and Adenomyosis: A Comprehensive Review.

Imaging of endometriosis and in particular deep endometriosis (DE) is crucial in the clinical management of women facing this debilitating condition. Transvaginal sonography (TVS) is the first-line imaging method and magnetic resonance imaging (MRI) may provide supplemental information. However, the delay in diagnosis of up to 10 years and more is of concern. This problem might be overcome by simple steps using imaging with emphasis on TVS and referral to tertiary care. Finally, TVS is crucial in mapping extent and location of disease in planning surgical therapy and counseling women regarding various therapeutic options. This review presents the available data on imaging of endometriosis with a focus on TVS and MRI for DE, adenomyosis, and ovarian endometriomas including endometriomas in pregnancy as well as the use of "soft markers." The review presents an approach that is in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement.

[Surgical treatment of benign gynecological disorders]. / Kirurgisk behandling av benigne gynekologiske lidelser.

BACKGROUND: All of Norway's inhabitants are entitled to health services of a good and equal quality. The aim of this study was to evaluate whether women with benign gynaecological disorder are treated according to this principle. Guidelines recommend that the laparoscopic technique should be used to operate ectopic pregnancies and ovarian cysts. Vaginal or laparoscopic technique should be used for hysterectomies. MATERIAL AND METHODS: Recording of surgical modality used in gynaecological departments in Norway to treat ectopic pregnancies, ovarian cysts and hysterectomies on the indication bleeding disorders and/or fibroids. Data were retrieved from the National Patient Register for the years 2003 - 06. RESULTS: The proportion of operations performed with laparotomy was gradually reduced for the conditions assessed during the period of observation. 24 % of women with ectopic pregnancies were operated with laparotomy in 2003 and 14 % in 2006; 50 % of women with ovarian cysts were operated with the technique in 2003 and 41 % in 2006. For hysterectomies due to bleeding disorders and/or fibroids, the frequency of laparotomies decreased from 75 % in 2003 to 62 % in 2006. Adherence to guidelines is best in departments that perform many operations. INTERPRETATION: Different surgical approaches are used to treat the same benign gynecological disorders in Norway. The reason for this difference has not been evaluated, but it may be explained by tradition, lack of competence and inadequate training of gynecologists.