Costs and charges associated with three alternative techniques of hysterectomy

BACKGROUND: Many hysterectomies are now performed by a laparoscopically assisted vaginal technique. This procedure is controversial, partly because of concern about cost. We studied hospital charges and costs for the procedure as compared with those for total abdominal hysterectomy and total vaginal hysterectomy in clinically similar groups of patients. METHODS: From hospital-discharge data and patients' charts, we identified hysterectomies performed in 1993 and 1994 by 96 surgeons at a community teaching hospital to treat benign conditions. The patients were grouped according to the surgical procedures performed in conjunction with the hysterectomy. Data on hospital charges and cost-to-charge ratios for 64 hospital cost centers were used to assess charges and costs for specific resources, as well as for the hospitalization overall. RESULTS: Of 1049 patients studied, 26 percent underwent laparoscopically assisted vaginal hysterectomy, 54 percent underwent abdominal hysterectomy, and 20 percent underwent vaginal hysterectomy. The average hospital stays were 2.6, 3.9, and 2.9 days, respectively, and the mean total charges (facility charges plus professional fees) for the hospitalizations were $6,116, $5,084, and $4,221 (P<0.001 for the comparison of the laparoscopic technique with both other techniques). The mean facility costs were $4,914, $3,954, and $3,116, respectively (P<0.001 for the same comparison), with similar findings in all subgroups. The higher charges and costs for laparoscopically assisted vaginal hysterectomy were due to higher supply costs, particularly when disposable supplies were used, and to longer operating-room time. CONCLUSIONS: Despite shorter hospital stays, in-hospital charges and costs for laparoscopically assisted vaginal hysterectomy are higher than for either alternative procedure, because of the disposable supplies that are typically used and the longer operating-room time.     

Costs of hysterectomy: does surgical approach make a difference?

We wanted to determine the direct cost of hysterectomies by surgical approach and to estimate the impact on costs if more vaginal hysterectomies were substituted for abdominal hysterectomies for women under 50 years of age. Eleven Ontario (Canada) hospitals provided 1994 cost data based on 1376 hysterectomies. These data were applied to all hysterectomies performed in the province for women under 50 to estimate the cost of subtotal, vaginal (VH), or laparoscopically assisted vaginal hysterectomy (LAVH) relative to total abdominal hysterectomy (TAH). We determined the change in costs if TAHs in Ontario in 1994-1995 had been substituted by VH or LAVH. Teaching and community hospitals were considered separately. VH was less costly than TAH, subtotal, or LAVH. The direct cost for TAH at teaching hospitals was much higher than at community hospitals. Costs relative to TAH were higher for LAVH at community but not at teaching hospitals. From the population baseline rate of 25% VH, 5% LAVH, 10% subtotal, and 60% TAH, we estimated that increasing VH to 45% would lower costs by 2.4%; increasing LAVH to 25% would increase costs by 4.4%. VH is associated with lower costs than TAH or LAVH. However, the magnitude of the substitution and the extent of cost savings should ultimately be based on evaluation of patient outcomes.     

Laparoscopic hysterectomy. Supracervical vs. assisted vaginal

Twenty cases of laparoscopic supracervical hysterectomy performed by operative laparoscopy without vaginal assistance were retrospectively compared to 232 cases of laparoscopically assisted vaginal hysterectomy reported in the literature. The specimens were morcellated intraabdominally and removed through the umbilicus. This is the first reported series of this technique with intraabdominal morcellation, which emphasizes cosmetic considerations and remains within the confines of the umbilicus. The postoperative hospitalization time ranged from 3.75 to 22.2 hours. On the second postoperative day, 10% of the patients returned to work, and 15% were able to drive. Patients resumed normal activity in an average of 5.6 days after surgery. As compared to laparoscopically assisted vaginal hysterectomy, there was a decrease in morbidity, blood loss and recovery time. Prolonged anesthesia from the longer operating time was clinically insignificant in terms of the patients' recovery. By decreasing the disability from hysterectomy from six weeks to one, the procedure provided financial savings through work time gained.     

Enzymatic phosphorylation of soy globulins by the protein kinase CK2. Determination of the phosphorylation sites of beta-conglycinin alpha subunit by mass spectrometry

Being quite experienced in the field of gynaecologic surgery and hysterectomies especially, being familiar with recent innovations in laparoscopic surgery and also having some own experience in laparoscopic surgery, the authors discuss the advantages and disadvantages of all surgical methods of hysterectomy. Comparing the techniques, the duration, bearing in mind the the risks, overall costs and all other surgical details, the authors concluded that laparoscopically assisted vaginal hysterectomy is the best choice because it is the least invasive, less risky, no scars are left, the postoperative recovery is quick, there are numerous indications for it, the preparation obtained as a whole can be used for further clinical examination. The only disadvantage is it is too costly and sometimes the operation itself lasts too long, so it should not be applied in some cases.     

Vaginal and abdominal hysterectomy: comparison and perspectives. Apropos of 385 consecutive cases

Hysterectomy is the most common non-pregnancy related surgical procedure. However, given the lack of final guidelines on indications, alternative therapies, surgical approach and outcomes, it is desirable to keep its use under constant monitoring. We reviewed 385 hysterectomies for benign conditions-divided according to surgical approach-performed in the Gynaecological Department of San Daniele del Friuli (Udine-Italy) in 1991-1993, and with one-year follow-up. Traditional approaches, i.e. abdominal (39.2%) and vaginal (60.2%), were used. Colporraphy was performed in 79 cases (33.8% of vaginal hysterectomies); 73.4% of colporraphies were followed by urethral suspension. We reviewed population's patterns, indications and surgical outcomes according to Dicker's suggestions. Vaginal hysterectomy with associated colporraphy concerned a population of patients with average age and parity significantly different from patients who underwent simple vaginal or abdominal hysterectomy. These last two groups, on the other hand, have similar characteristics making them comparable. In abdominal hysterectomy and simple vaginal hysterectomy we reported a complication rate respectively of 21.9% and 7.1%. The advantages of simple vaginal hysterectomy include shorter operating time, reduction in antibiotic drugs usage, earlier hospital discharge and quicker recovery, with obvious cost saving. Our experience therefore supports the view that the balance between abdominal and vaginal hysterectomy could safely be shifted in favour of the last one, the advantages of which could then be made available to a larger number of patients.     

Tissue expander complications in the pediatric burn patient

OBJECTIVES: The main purpose of our study was to identify the patient characteristics of women undergoing hysterectomy and to estimate the proportion of hysterectomies that could be done vaginally by recognized surgical techniques. STUDY DESIGN: The records of 500 women who underwent hysterectomy were reviewed. The characteristics of patients without an absolute contraindication to vaginal hysterectomy were analyzed. RESULTS: Overall, 96 (19.2%) of our study group underwent vaginal hysterectomy. A total of 382 (76.4%) women were judged not to have an absolute contraindication to this route. The most frequent characteristics of this group were lack of uterine prolapse (76.4%), a myomatous uterus (44.5%), and a need for oophorectomy (43.2%). We did not exclude women who did not have significant uterine prolapse or a history of pelvic surgery or pelvic tenderness and we included those requiring oophorectomy or with a uterine size up to that of 14 weeks' gestation; with these criteria more than two thirds of the entire study population could undergo vaginal surgery. CONCLUSIONS: To maximize the proportion of hysterectomies performed vaginally, gynecologists need to be familiar with surgical techniques for dealing with nonprolapsed uteri, uterine leiomyomas, and vaginal oophorectomy.     

Hysterectomy trends in Finland in 1987-1995--a register based analysis

BACKGROUND: The study objective was to identify trends in the use of hysterectomy by nationwide register based analysis in Finland. METHODS: All women (n=89,069) undergoing hysterectomy in 1987-1995 according to the Finnish Hospital Discharge Register were the numerator. The annual denominator data were obtained from the population database of Statistics Finland. RESULTS: From 1987 to 1992 the hysterectomy rate increased by 22%, from 340 to 414 per 100,000 females, almost half of this being attributable to the changing age structure. From 1993 on, ambiguity in coding laparoscopically assisted vaginal hysterectomies prohibited detailed analyses. However, the overall trend continued at least among women 50 years and over until 1995. The age-adjusted 12% increase from 1987 to 1992 coincided with a rapid increase in operation rates in postmenopausal groups (60% or more among women aged 55 59 and 70-79 years). Among women aged 55-64 years, operations for fibroids and uterine bleeding more than doubled, suggesting an influence of increased use of estrogen replacement therapy. Among all women, operations due to bleeding disorders and genital prolapse showed the largest increase (41% and 42% respectively). Bilateral oophorectomy became more common in all age groups over 46 years. CONCLUSIONS: There was a modest increase in the overall hysterectomy rate. However, the operation became far more common in postmenopausal women, possibly due to the growing use of estrogen replacement therapy. Register data can be used for describing changes in clinical practice, but other methods are needed to confirm the causal relationships underlying the changes.     

Cesarean hysterectomy im modern obstetrical practice from 1968 to 1993

A retrospective study of cesarean hysterectomies at the Department of Obstetrics and Gynecology in Novi Sad was conducted for the period 1968-1993. There were 129,127 deliveries, whereas cesarean section was performed in 10,485 (8.12%) cases. There were 55 cesarean hysterectomies (0.042%), while in 0.52% they were performed during cesarean section. Elective hysterectomy was performed in 7 (12.73%) cases because of neoplastic process and uterine myoma, while in 48 (87.27%) cases it was performed for heavy bleeding. Most often bleeding occurred due to complications of placenta previa, uteroplacental apoplexy, premature placental ablation, uterine rupture and atony. Total hysterectomy was performed in 30 (54.54%) cases and subtotal hysterectomy in 25 (45.45%) cases. Bilateral adnexectomy was performed in 3 (5.45%) cases. Urinary bladder injury occurred in 4 (7.27%) patients, wound infection in 11 (20.00%) patients, urinary infection in 3 (5.45%) and pelvic peritonitis in 1 (1.82%) patient. One maternal death (1.82%) occurred due to DIC (disseminated intravascular coagulation). Out of 57 delivered newborns 20 (35.10%) died in the perinatal period. There were 13 stillbirths (22.80%), whereas 7 newborns (12.30%) died in the early neonatal period due to prematurity and RDS (respiratory distress syndrome).     

A technique for laparoscopic completion of vaginal hysterectomy

Recently, the use of laparoscopic assistance in vaginal hysterectomy has become popular, although its role in gynecologic surgery has not been well established. A way to define this role is to start the hysterectomy vaginally and use laparoscopic assistance only if it becomes necessary. We present a new technique in which vaginal hysterectomy proceeds to the opening of the peritoneal reflections and ligature of uterine vessels and uterosacral ligaments. If laparoscopic assistance becomes necessary at this point, a uterine manipulator with an adapted inflatable balloon is inserted vaginally, allowing completion of the procedure laparoscopically while maintaining a pneumoperitoneum. Eight operations were performed successfully in our institution using this new technique. Operative time was less than with conventional laparoscopically assisted vaginal hysterectomy. The technique also simplified the management of the uterine vessels and detachment of the bladder.     

Vaginal hysterectomy for the large uterus

OBJECTIVE: To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size. DESIGN: A prospective observational study. SETTING: The Royal Free Hospital, London. PARTICIPANTS: Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size. INTERVENTIONS: Vaginal hysterectomy with or without bilateral salpingo-oophorectomy or oophorectomy. MAIN OUTCOME MEASURES: Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra- and post-operative complications, duration of hospitalisation. RESULTS: The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (n = 6) and superficial vaginal grazes (n = 5). One of the women required a blood transfusion. The mean post-operative hospital stay was 3.7 days (range 2 to 9 days). CONCLUSION: Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.     

Is laparoscopic hysterectomy a waste of time?

Laparoscopic hysterectomy (LH) is a way to avoid laparotomy. However, there is evidence that most women treated by abdominal hysterectomy are suitable for vaginal surgery. To test this hypothesis, and to determine the relative merits of laparoscopic and vaginal hysterectomy (VH) and the best technique for LH, we prospectively studied 98 women who had relative contraindications for vaginal surgery by traditional criteria. 75 underwent LH and 23 VH. The LH group included 22 women who had been assigned to this route of surgery as part of a prospective randomised controlled comparison with VH (23 women). Surgery was completed with the intended technique in 93.9% of cases. 5 women in the LH group (6.7%) and 2 in the VH group required laparotomy or additional procedures. In the prospective randomised study LH took longer than VH (mean duration 131 vs 77 min). VH was the faster procedure, irrespective of uterine size and need for oophorectomy. With LH, the operative time increased as more of the hysterectomy was carried out with laparoscopic rather than vaginal dissection. Complication rates, blood loss, analgesia requirements, and recovery were similar for the two techniques. Our study confirms that most hysterectomies could be performed vaginally, and that LH is a much slower procedure. If LH is done, it should be converted to a vaginal procedure as early as possible to reduce the overall operating time. LH does seem to be a waste of time for most patients.     

Treatment with a gonadotrophin releasing hormone agonist before hysterectomy for leiomyomas: results of a multicentre, randomised controlled trial

OBJECTIVES: To ascertain whether uterine shrinkage induced by a gonadotrophin releasing hormone agonist before hysterectomy for fibroids increases the possibility of a vaginal procedure. DESIGN: A multicentre, prospective, randomised, controlled study. PARTICIPANTS: One hundred and twenty-seven premenopausal women with a uterine volume of 12 to 16 gestational weeks. INTERVENTIONS: Twelve weeks of triptorelin depot treatment before hysterectomy or immediate surgery. MAIN OUTCOME MEASURES: Number of vaginal and abdominal hysterectomies, operating time, blood loss, degree of difficulty of the procedure, perioperative serum haemoglobin and haematocrit levels, hospital stay, and patients' overall satisfaction with treatment. RESULTS: After randomisation, four women withdrew from the study, leaving 60 women in the triptorelin arm and 63 in the immediate surgery arm. At baseline evaluation a vaginal hysterectomy was indicated in seven women allocated to pre-operative medical therapy (12%), and in 10 of those allocated to immediate surgery (16%). Clinical assessment after the 12-week GnRH agonist course showed that abdominal hysterectomy was no longer indicated in 25/53 women (47%) as a vaginal procedure appeared appropriate. Thus the overall rate of indication for a vaginal procedure in the pre-operative medical treatment arm was 32/60 cases (53%), with a between-group difference of 37% (95% CI, 26% to 51%; chi2(1) = 19.18, P < 0.0001; OR 6.06; 95% CI, 2.60 to 14.10). Pre- and post-operative serum haemoglobin and haematocrit levels were significantly higher in the GnRH agonist than in the immediate surgery arm. No appreciable difference was observed between the groups in the other intra- and post-operative variables, including patients' satisfaction. CONCLUSIONS: Pre-operative GnRH agonist therapy increased the rate of vaginal hysterectomy in selected women with fibroids and uterine volume of 12 to 16 gestational weeks.     

Laparoscopic ovarian transposition for pelvic malignancies: indications and functional outcomes

OBJECTIVE: To assess the indications and effectiveness of laparoscopic ovarian transposition before pelvic irradiation for a gynecologic cancer. DESIGN: Prospective study. SETTING: A gynecologic oncology department in a French anti-cancer center. PATIENT(S): Twenty-four patients treated for pelvic cancer. INTERVENTION(S): Laparoscopic ovarian transposition to paracolic gutters. Uterine conservation in 18 patients. MAIN OUTCOME MEASURE(S): Clinical and laboratory follow-up tests of ovarian function. RESULT(S): Bilateral laparoscopic ovarian transposition was achieved in 22 patients (94%). Twelve patients were treated for clear cell adenocarcinoma of the cervix and/or upper vagina, 6 patients for invasive squamous cervical carcinoma, 3 patients for pelvic sarcoma, 1 patient for recurrent cervical cancer to the upper vagina, 1 patient for ependymoma of the cauda equina, and 1 patient for ovarian dysgerminoma. Ovarian preservation was achieved in 79%. Three pregnancies were obtained. CONCLUSION(S): Laparoscopic ovarian transposition is a safe and effective procedure for preserving ovarian function. Bilateral ovarian transposition should be performed. The main indications for laparoscopic ovarian transposition are a patient with a small invasive cervical carcinoma (<2 cm) in a patient <40 years of age who is treated by initial laparoscopically assisted vaginal radical hysterectomy and a patient with a clear cell adenocarcinoma of the cervix and upper vagina.     

Indications for laparoscopic surgery in cases of gynecological malignancies (endometrial cancer)

The role of surgery in the treatment of patients with invasive cervical cancer is undisputed, but how radical surgery should be is debatable. Every case requires detailed knowledge of the development and spread of cervical cancer. Tumor volume is the most important diagnostic factor in cervical cancer and also correlates with vascular invasion and lymph node involvement. As radical hysterectomy requires in cervical cancer besides the laparoscopically easy performable lymphadenectomy also the resection of parametria with sceletonisation of ureters we started to treat endometrial cancer with a combined laparoscopic and vaginal approach. In patients with the suspicion of stage I endometrial cancer prior to laparoscopic staging, the prerequisites of histological grading with ploidy and measurement of monoclonal antibodies were performed. All patients underwent a general check with radiography, computer tomography, liver scan, bone scan and lymphography. The performance of lymphadenectomy in cases of stage I endometrial cancer remains a controversial subject. We believe that laparoscopic assisted surgical staging of stage I endometrial cancer is an attractive alternative to the traditional laparotomy-surgical approach. The change from laparotomy to a laparoscopic assisted vaginal approach allows for a similar success rate with the less invasive approach. No complications occurred in this series and the results of our pilot study were satisfactory.     

Necrotizing fasciitis following laparoscopic surgery. Case report and review of the literature

Necrotizing fasciitis is a rare and potentially fatal infection characterized by rapid and progressive involvement of the fascia and subcutaneous tissues. Early diagnosis, aggressive initial debridement followed by planned redebridements in conjunction with nutritional support and antibiotics remain the mainstay of therapy. We present a case of necrotizing fasciitis of the abdominal wall following a laparoscopically assisted vaginal hysterectomy. Literature is reviewed and discussed with reference to this catastrophic infection in the age of laparoscopic surgery.     

An inexpensive light source for oncologic photodynamic therapy

The advantages obtained in vaginal surgery and caesarean section using spinal anesthesia led us to test this anesthesia to verify feasibility, problems and advantages in abdominal surgery. Spinal anesthesia was performed in 60 patients between 21 and 87 years of age. Thirty-seven total abdominal hysterectomies with or without adnexectomy, 5 laparotomic miomectomies, 3 adnexectomies, 5 colposacropexies, 2 hysterectomies with lymphadenectomy, 7 Burch colposuspension with or without hysterectomy and 1 laparoscopy for sterilization were performed. No significant problems during surgery and the postoperative period were observed. Resumption of the different physiologic functions were more rapid, hospital stay shorter and compliance greater than with general anesthesia.     

Comparison of systemic and mucosal priming for mucosal immune responses to a bacterial protein antigen given with or coupled to cholera toxin (CT) B subunit, and effects of pre-existing anti-CT immunity

The advantages of the laparoscopic mode of access for hysterectomy include shorter recovery time and less pain and scarring. The laparoscopic component of the hysterectomy is usually combined with a vaginal component. The relative proportions of the procedure, performed laparoscopically and vaginally, vary considerably between surgeons. The main problem associated with the laparoscopic approach is to ensure adequate hemostasis while avoiding damage to the urinary tract. A variety of differing techniques have been developed in attempts to ensure the safe and efficient removal of the uterus laparoscopically.     

Laparoscopically assisted vaginal hysterectomy

OBJECTIVE: To report our experience with laparoscopically assisted vaginal hysterectomy (LAVH) and evaluate the advantages of LAVH. STUDY DESIGN: From January 1991 to August 1992, 176 LAVHs were performed at the Department of Obstetrics and Gynecology, College of Medicine, Chung-Ang University, Seoul, Korea. The indications for LAVH, based on the preoperative diagnosis, were uterine myomas, dysmenorrhea, chronic pelvic inflammatory disease or pelvic pain, dysfunctional uterine bleeding and cervical intraepithelial neoplasia (in order of frequency). RESULTS: Patients had concomitant procedures, including incidental appendectomy, posterior wall repair, pelvic adhesiolysis and salpingo-oophorectomy. Bipolar forceps were used to compress and desiccate vessels. The Nd-YAG laser, scissors and/or unipolar electrode were used for tissue division, excision of adhesions and cutting. The intraoperative complications were bladder perforation, massive hemorrhage and inferior epigastric vessel injury (one case each). The postoperative complications were infection, voiding difficulty, febrile morbidity, pelvic abscess, incisional hernia, vaginal vault bleeding and peroneal nerve palsy (one case each). CONCLUSION: Hysterectomy can be safely performed vaginally assisted by operative laparoscopy by well-trained laparoscopists, resulting in reduced surgical morbidity, blood loss, postoperative discomfort, recovery time and hospitalization.     

A randomized controlled trial of extraperitoneal bupivacaine analgesia in laparoscopic hernia repair

BACKGROUND: This study was designed to determine the frequency of surgical site infection development after discharge from the hospital after abdominal or vaginal hysterectomy and the frequency of use of antimicrobial prophylaxis in this patient group. METHODS: A prospective cohort study was performed on patients undergoing abdominal or vaginal hysterectomy between February 1 and December 31, 1995. Surgeons were contacted 1 month after the operations to determine which patients had acquired surgical site infections. Surgical site infection rates were calculated according to procedure, surgeon, and National Nosocomial Infection Surveillance system risk categories. A retrospective pharmacy record review was conducted to determine antimicrobial prophylaxis use according to procedure and surgeon. RESULTS: A total of 763 cases were surveyed; 55 (7.2%) met criteria for postoperative surgical site infection (7.7% abdominal and 4.5% vaginal hysterectomy). National Nosocomial Infection Surveillance system moderate-risk patients had significantly higher infection rates than did low-risk patients for both abdominal (p = 0.045) and vaginal (p = 0.05) procedures. Most patients (71.1%) were not given antimicrobial prophylaxis. There was a wide range of antimicrobial prophylaxis use by surgeon (3.6% to 94.4% of patients, p < 0.01). CONCLUSION: Despite long-standing and widespread recommendations for antimicrobial prophylaxis before hysterectomy, most of our patients were operated on without such prophylaxis. Surveillance programs permit detailed review of patient care practices that may reveal opportunities for improvement.     

Identification of mRNA, localized at various segments of the Xenopus laevis embryo at early stages of the gastrula

METHODS: In a randomized double-blind study, 134 patients were given 500 mg metronidazole as an intravenous infusion immediately before operation for abdominal total hysterectomy and again 8 hours later and 124 patients received placebo. RESULTS: There was more wound infection, postoperative hospitalization was longer and the sedimentation rate on the sixth postoperative day was significantly higher in the placebo group. There was no difference in postoperative temperature. Postoperative wound infections occurred in 12% in the placebo group and 6% in the metronidazole group. Eight percent in the total material had urinary tract infections, the diagnosis was based on urine cultures. CONCLUSIONS: Prophylaxis with intravenous infusion of metronidazole is recommended in total hysterectomies.