To assess if women with obesity have increased complication rates compared with women with normal weight undergoing hysterectomy for benign reasons and if the mode of hysterectomy affects the ...outcomes.
Cohort study.
Prospectively collected data from 3 Swedish population-based registers.
Women undergoing a total hysterectomy for benign indications in Sweden between January 1, 2015, and December 31, 2017. The patients were grouped according to the World Health Organization's classification of obesity.
Intraoperative and postoperative data were retrieved from the surgical register up to 1 year after the hysterectomy. Different modes of hysterectomy in patients with obesity were compared, such as open abdominal hysterectomy (AH), traditional laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and robot-assisted laparoscopic hysterectomy (RTLH).
Out of 12,386 women who had a total hysterectomy during the study period, we identified 2787 women with normal weight and 1535 women with obesity (body mass index ≥30). One year after the hysterectomy, the frequency of complications was higher in women with obesity than in women with normal weight (adjusted odds ratio aOR) 1.4; 95% confidence interval CI, 1.1–1.8). In women with obesity, AH was associated with a higher overall complication rate (aOR 1.8; 95% CI, 1.2–2.6) and VH had a slightly higher risk of intraoperative complications (aOR 4.4; 95% CI, 1.2–15.8), both in comparison with RTLH. Women with obesity had a higher rate of conversion to AH with conventional minimally invasive hysterectomy (TLH: aOR 28.2; 95% CI, 6.4–124.7 and VH: 17.1; 95% CI, 3.5–83.8, respectively) compared with RTLH. AH, TLH, and VH were associated with a higher risk of blood loss >500 mL than RTLH (aOR 11.8; 95% CI, 3.4–40.5; aOR 8.5; 95% CI, 2.5–29.5; and aOR 5.8; 95% CI, 1.5–22.8, respectively) in women with obesity.
The use of RTLH may lower the risk of conversion rates and intraoperative bleeding in women who are obese compared with other modes of hysterectomy.
(Abstracted from Obstet Gynecol 2020;135:341–351)Perineal trauma and tears during vaginal childbirth is common in primiparous women. Reported rates of perineal tears range from 47% to 78%.
Introduction
High body mass index (BMI) is a risk‐factor for stress urinary incontinence (SUI). Mid‐urethral sling (MUS) surgery is an effective treatment of SUI. The aim of this study was to ...investigate if there is an association between BMI at time of MUS‐surgery and the long‐term outcome at 10 years.
Material and Methods
Women who went through MUS surgery in Sweden between 2006 and 2010 and had been registered in the Swedish National Quality Register of Gynecological Surgery were invited to participate in the 10‐year follow‐up. A questionnaire was sent out asking if they were currently suffering from SUI or not and their rated satisfaction, as well as current BMI. SUI at 10 years was correlated to BMI at the time of surgery. SUI at 1 year was assessed by the postoperative questionnaire sent out by the registry. The primary aim of the study was to investigate if there is an association between BMI at surgery and the long‐term outcome, subjective SUI at 10 years after MUS surgery. Our secondary aims were to assess whether BMI at surgery is associated with subjective SUI at 1‐year follow‐up and satisfaction at 10‐year follow‐up.
Results
The subjective cure rate after 10 years was reported by 2108 out of 2157 women. Higher BMI at the time of surgery turned out to be a risk factor for SUI at long‐term follow‐up. Women with BMI <25 reported subjective SUI in 30%, those with BMI 25—<30 in 40%, those with BMI 30—<35 in 47% and those with BMI ≥35 in 59% (p < 0.001). Furthermore, subjective SUI at 1 year was reported higher by women with BMI ≥30, than among women with BMI <30 (33% vs. 20%, p < 0.001). Satisfaction at 10‐year follow‐up was 82% among women with BMI <30 vs 63% if BMI ≥30 (p < 0.001).
Conclusions
We found that higher BMI at the time of MUS surgery is a risk factor for short‐ and long‐term failure compared to normal BMI.
Treating stress urinary incontinence with a mid‐urethral sling seems to be more effective if you have a BMI <30 than if you are obese and have a BMI ≥30.
Introduction
The widespread misuse of prescription pain medication, including opioids, has serious public health implications. Postoperative pain is a risk factor for persistent or chronic pain ...unless treated effectively. There are only a few studies that have assessed the use of opioid‐containing drugs after gynecological surgery and most of these usually have a short follow‐up period. The aim of this study was to identify risk‐factors for long‐term use of prescription opioid drugs following hysterectomy.
Material and methods
We performed a nationwide cohort study based on prospectively collected data. Information from two population‐based registers, the Swedish National Quality Register of Gynecological Surgery and the Swedish National Drug Register, was linked. The study population consisted of women with benign disease undergoing a total hysterectomy from 1 January 2012 until 31 December 2015. To identify long‐term changes in prescription of opioids, individual data were collected from 1 year prior to to 3 years after surgery between 2011 and 2018. Data analysis was performed using multivariable logistic regression models.
Results
The population included 17 385 women having had hysterectomy for benign disease. Of these women, 4233 (24.4%) were prescribed analgesics continuously for 3 years postoperatively and 1225 (7.1%) used opioids long term. Perioperative predictors of opioid use 3 years after surgery included a diagnosis of adenomyosis (adjusted odds ratio aOR 1.8, 95% confidence interval CI 1.2‐2.7) and preoperative use of opioids (aOR 29.6, 95% CI 19.7‐44.4), psycho‐ (aOR 3.5, 95% CI 2.4‐5.0) and neuroactive drugs (aOR 1.8, 95% CI 1.0‐3.1). For women with no opioid prescription preoperatively (n = 260, 1.5%), mild (aOR 2.8, 95% CI 1.1‐7.3) and severe (3.0% vs 6.2%: aOR 6.4, 95% CI 1.4‐20.0) postoperative complications and preoperative prescription of psychoactive drugs (aOR 4.6, 95% CI 1.9‐10.7) were associated with long‐term use of drugs containing opioids.
Conclusions
Long‐term use of prescription opioids after hysterectomy is common and is, among other risk factors, strongly associated with preoperative use of opioids, as well as psychoactive drugs and adenomyosis. To avoid opioid misuse disorders among women at risk for long‐term opioid drug prescriptions after hysterectomy, further studies and strategies are needed.
Introduction
The study aims to analyze differences between robot‐assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon ...and hospital volume.
Material and methods
All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo‐oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses.
Results
TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios aOR 2.8, 95% CI 1.3–5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2–2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2–25.4), a higher blood loss (200–500 mL aOR 3.5, 95% CI 2.7–4.7; > 500 mL aOR 7.6, 95% CI 4.0–14.6) and a longer operative time (1–2 h aOR 16.7 95% CI 10.2–27.5; >2 h aOR 47.6, 95% CI 27.9–81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4–0.9).
Conclusions
RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low‐volume surgeons but persisted across all surgeon volume groups.
OBJECTIVE:To evaluate outcomes after pelvic floor muscle therapy, as compared with perineorrhaphy and distal posterior colporrhaphy, in the treatment of women with a poorly healed second-degree ...obstetric injury diagnosed at least 6 months postpartum.
METHODS:We performed a single center, open-label, randomized controlled trial. After informed consent, patients with a poorly healed second-degree perineal tear at minimum 6 months postpartum were randomized to either surgery or physical therapy. The primary outcome was treatment success, as defined by Patient Global Impression of Improvement, at 6 months. Secondary outcomes included the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the Hospital Anxiety and Depression Scale. Assuming a 60% treatment success in the surgery group and 20% in the physical therapy group, plus anticipating a 20% loss to follow-up, a total of 70 patients needed to be recruited.
RESULTS:From October 2015 to June 2018, 70 of 109 eligible patients were randomized, half into surgery and half into tutored pelvic floor muscle therapy. The median age of the study group was 35 years, and the median duration postpartum at enrollment in the study was 10 months. There were three dropouts in the surgery group postrandomization. In an intention-to-treat analysis, with worst case imputation of missing outcomes, subjective global improvement was reported by 25 of 35 patients (71%) in the surgery group compared with 4 of 35 patients (11%) in the physical therapy group (treatment effect in percentage points 60% 95% CI 42–78%, odds ratio 19 95% CI 5–69). The surgery group was superior to physical therapy regarding all secondary endpoints.
CONCLUSION:Surgical treatment is effective and superior to pelvic floor muscle training in relieving symptoms related to a poorly healed second-degree perineal tear in women presenting at least 6 months postpartum.
CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT02545218.
•Nationwide register study.•Hysterectomized with endometriosis – frequent complications.•Robotic – less conversions.
To assess whether hysterectomy in patients with endometriosis is associated with ...higher proportion of complications compared with patients without, and whether route of hysterectomy affects this outcome.
This is a population-based retrospective cohort study. Data were prospectively obtained from three National Swedish Registers. Patients undergoing a benign hysterectomy between 2015 and 2017 in Sweden were included in the study and were grouped according to a histology-proven diagnosis of endometriosis. Different hysterectomy modes were compared in patients with endometriosis. Perioperative data and postoperative complications up to 1 year after surgery were collected and measured.
In all, 8,747 patients underwent a benign hysterectomy, and 1,166 patients with endometriosis was compared with 7,581 patients without. Patients with endometriosis had higher proportion of complications (adjusted Odds ratio aOR 1.2, 95% CI 1.0–1.4), were more often converted to abdominal hysterectomy (aOR 1.7, 95% CI 1.1–2.6), had higher estimated blood loss (EBL) (200–500 ml; aOR 1.8, 95% CI 1.4–2.3, >500 ml; aOR 3.1, 95% CI 2.2–4.4) and a longer operative time (1–2 h; aOR 2.1, 95% CI 1.4–3.2, >2 h; aOR 4.3, 95% CI 2.7–6.6) than endometriosis-free patients. The conversion rate was 13.8 times higher in total laparoscopic hysterectomy (TLH) compared with robotic-assisted laparoscopic hysterectomy (RATLH) (aOR 13.8, 95% CI 3.6–52.4).
Higher conversion rate, higher EBL and higher frequency of complications were seen in patients with endometriosis. RATLH was associated with lower conversion rate compared to TLH.
Introduction
One in three women with pelvic organ prolapse (POP) undergoing surgery have a relapse. Currently, no optimal surgical treatment has been identified for correcting a uterine prolapse. ...This population‐based register study aims to compare the relapse rate in patients with uterine prolapse undergoing hysterectomy with suspension or uterine‐sparing surgical procedures.
Material and methods
All women with uterine prolapse undergoing prolapse surgery in Sweden from January 1, 2015 to December 31, 2018, were identified from the Gynecological Operation Register (GynOp). The primary outcome was the number of recurrent POP surgeries up to December 31, 2020.
Results
Sacrospinous hysteropexy (SSHP) without graft and sacrohysteropexy (SHP) were associated with a significantly higher rate of recurrent POP surgery (SSHP without graft: adjusted odds ratio aOR 2.6, 95% CI 2.0–3.5; SHP aOR 2.6, 95% CI 1.8–3.7) and patients describing a sense of globe (SSHP without graft, aOR 2.0, 95% CI 1.6–2.6; SHP, aOR 1.8, 95% CI 1.1–3.1) compared with cervical amputation with uterosacral ligament fixation (Manchester procedure). There was no difference in the reoperation rate or sense of a globe between SSHP with graft and Manchester procedure. Patients undergoing SSHP without graft had a higher frequency of 1‐year postoperative complications compared with Manchester procedure (aOR 2.0, 95% CI 1.6–2.6) and SHP (aOR 2.4, 95% CI 1.4–3.9). Moreover, the frequency of 1‐year postoperative complications was higher in SSHP with graft (aOR 1.6, 95% CI 1.1–2.2) than in Manchester procedure.
Conclusions
The Manchester procedure was associated with a low rate of recurrent POP surgery, symptomatic recurrence and low surgical morbidity compared with other surgical methods in women with uterine prolapse.
Introduction
In surgical repair of pelvic organ prolapse the recurrence rate is about 30% and the importance of apical support was recently highlighted. In surgical randomized controlled studies, the ...external validity can be compromised because the surgical outcomes often depend on surgical volume. Therefore, we sought to study outcomes of surgical treatment in patients with vaginal vault prolapse in a nationwide setting with a variety of surgical volumes.
Material and methods
This is a nationwide cohort study. All patients with a vaginal vault prolapse undergoing surgery, between January 1, 2015 and December 31, 2018, were identified from the Swedish National Quality Register of Gynecological Surgery, GynOp. The primary outcome was the frequency of recurrent pelvic organ prolapse surgery within 2 years postoperatively. Secondary outcomes included patient‐reported vaginal bulging, operative time, estimated blood loss and 1‐year postoperative complications.
Results
In 1812 patients with vaginal vault prolapse, 538 (30%) had a sacrospinous ligament fixation (SSLF) with graft, 441 (24%) underwent SSLF without graft, and 200 (11%) underwent minimally invasive sacrocolpopexy (SCP) or sacrocervicopexy (SCerP). A significantly higher proportion of patients undergoing recurrent pelvic organ prolapse surgery was seen in SSLF without graft than in SSLF with graft (adjusted odds ratio aOR 2.2, 95% CI 1.4–3.6). Patient‐reported sensation of vaginal bulging 1 year after surgery was higher in the SSLF group without graft than in the SSLF group with graft (aOR 1.9, 95% CI 1.3–2.8) and in the SCP/SCerP group (aOR 2.0, 95% CI 1.1–3.4). Finally, we found a significantly higher rate of complications 1 year after surgery in SSLF without graft (aOR 2.3, 95% CI 1.2–4.2) and in SSLF with graft (aOR 2.2, 95% CI 1.2–4.2) compared with SCP/SCerP.
Conclusions
In patients with vaginal vault prolapse, SSLF without graft was associated with a higher frequency of recurrent pelvic organ prolapse surgery compared with SSLF with graft, and a higher subjective relapse rate compared with SCP/SCerP and SSLF with graft. Additionally, the complication rate 1 year after primary surgery was higher in SSLF both with and without graft than in SCP/SCerP.
Introduction and hypothesis
The mid-urethral sling (MUS) has been used for more than 30 years to cure stress urinary incontinence. The objective of this study was to assess whether surgical technique ...affects the outcome after more than ten years, regarding dyspareunia and pelvic pain.
Methods
In this longitudinal cohort study we used the Swedish National Quality Register of Gynecological Surgery to identify women who underwent MUS surgery in the period 2006–2010. Out of 4348 eligible women, 2555 (59%) responded to the questionnaire sent out in 2020–2021. The two main surgical techniques, the retropubic and the obturatoric approach, were represented by 1562 and 859 women respectively. The Urogenital Distress Inventory-6 (UDI-6) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), as well as general questions concerning the MUS surgery, were sent out to the study population. Dyspareunia and pelvic pain were defined as primary outcomes. Secondary outcomes included PISQ-12, general satisfaction, and self-reported problems due to sling insertion.
Results
A total of 2421 women were included in the analysis. Among these, 71% responded to questions regarding dyspareunia and 77% responded to questions regarding pelvic pain. In a multivariate logistic regression analysis of the primary outcomes, we found no difference in reported dyspareunia (15% vs 17%, odds ratio (OR) 1.1, 95% CI 0.8–1.5) or in reported pelvic pain (17% vs 18%, OR 1.0, 95% CI 0.8–1.3) between the retropubic and obturatoric techniques among study responders.
Conclusion
Dyspareunia and pelvic pain 10–14 years after insertion of a MUS do not differ with respect to surgical technique.
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