Total laparoscopic hysterectomy using the harmonic scalpel.
(25/1277)
Total laparoscopic hysterectomy (TLH) is the complete hysterectomy including transection of the uterine vessels and opening/closure of the vaginal vault performed laparoscopically. This procedure can be performed as an alternative to total abdominal hysterectomy in many cases. We previously found use of the harmonic scalpel to be extremely helpful in performing laparoscopically assisted vaginal hysterectomies. In this series, the harmonic scalpel was used to facilitate performing TLH. Our experience has shown this can be performed without major complications in a cost-effective manner. (+info)
Endometriosis ascites: a case report.
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This is a case presentation of an usual nature, a 43-year-old Hispanic female, multigravida presenting with physical findings of massive ascites. In most instances, the presence of massive ascites is associated with malignancies, tuberculosis or perforated visous. In this case, the diagnosis of extensive endometriosis with ascites is reported as a very rare complication of the disease. (+info)
Hysterectomy techniques used for benign pathologies: results of a French multicentre study.
(27/1277)
The objective of this study was to assess the techniques by which hysterectomies are carried out and to determine the rate of total laparoscopic hysterectomy (TLH). A transversal multicentre study was conducted in 23 gynaecology and obstetrics departments of French University Hospital Centres. The study population comprised only those patients for whom hysterectomy was indicated for benign disease without genital prolapse or urinary stress incontinence. Whereas the rates of performance of hysterectomy by laparotomy and by the vaginal route are comparable [respectively 40.0% (94 patients) and 46.8% (110 patients)], the rate of performance of TLH is only 13.2% (31 patients). All 23 centres (100%) carried out hysterectomy by laparotomy and 21 centres (91.3%) carried out vaginal hysterectomy; however, only nine centres (39.1%) carried out TLH. Only seven centres (30.4%) performed all three types of operation. Of the eight centres whose rate of vaginal hysterectomy was >60%, six (75%) did not carry out TLH. The study suggests that the usage of the TLH technique appears to be limited. The extent of surgical training is a major factor in the choice of technique for hysterectomy. (+info)
Continuation of postmenopausal hormone replacement therapy in a large health maintenance organization: transdermal matrix patch versus oral estrogen therapy.
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OBJECTIVE: To determine possible differences in continuation of postmenopausal estrogen replacement therapy among women initiating treatment with transdermal estradiol versus those initiating treatment with oral estrogen. STUDY DESIGN: A retrospective database search. PATIENTS AND METHODS: We analyzed estrogen use among 45- to 74-year-old women who filled index prescriptions for estrogen during 1996 for either once-a-week transdermal estradiol or daily oral estrogen. Prescription use was analyzed separately for each of 2 groups: 276 hysterectomized women who filled prescriptions for estrogen alone (ERT) and 4182 women who filled prescriptions for medroxyprogesterone acetate (MPA) with estrogen (HRT) on the same day. RESULTS: Risk of discontinuing therapy after 12 months ranged from 59% to 76% among the 4 subgroups: ERT with unopposed transdermal estradiol; ERT with unopposed oral estrogen; HRT with MPA-opposed transdermal estradiol; and HRT with MPA-opposed oral estrogen. The relative risk (RR) of discontinuation was significantly greater among women starting HRT with transdermal estradiol than among women starting oral estrogen (RR = 1.5; 95% confidence interval [CI] = 1.3 to 1.8). RR of discontinuation among women starting ERT with transdermal estradiol compared with women starting oral estrogen therapy was 1.3 (95% CI = 1.0 to 1.8). CONCLUSIONS: Approximately 2 of 3 women who start either ERT or HRT discontinue therapy within a year, regardless of hysterectomy status. Furthermore, women who start ERT or HRT with a transdermal estradiol system are more likely to discontinue therapy. (+info)
Histological analysis of the uterine junctional zone as seen by transvaginal ultrasound.
(29/1277)
OBJECTIVE: This study aimed to investigate the histology of the subendometrial halo, the junctional zone between the endometrium and myometrium. METHODS: Thirteen ex vivo uteri removed for treatment of menorrhagia were studied. In each case, the subendometrial halo, as seen by transvaginal ultrasound, was marked using a Nottingham breast location biopsy needle. A standard histological examination was performed. Full thickness blocks of the anterior uterine wall were taken and standard serial 5-micron tissue sections were prepared from each block. Subsequent morphometric analysis followed staining with Feulgen reagent, using a CAS 200D quantitative image analysis system. Additionally, anti-CD31, an antibody stain for vascular endothelium, was used. RESULTS: The histological examination showed the subendometrial halo to consist of apparently normal myometrium. Morphometric analysis demonstrated a greater total nuclear area in the subendometrial halo than the outer myometrium, but no difference in individual nuclear size between the two zones. CD31 stained a greater total area in the inner myometrium. CONCLUSIONS: These results suggest that the subendometrial halo is a distinct compartment of the myometrium comprising tightly packed muscle cells with an increased vascularity. Such architecture would increase the density of this tissue layer, altering its acoustic impedance, and account for its echopenic appearance on ultrasound. (+info)
Effect of the frequency of transcutaneous electrical nerve stimulation on the postoperative opioid analgesic requirement and recovery profile.
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BACKGROUND: Transcutaneous electrical nerve stimulation (TENS) at either an acupoint or dermatome corresponding to the surgical incision produces comparable decreases in postoperative opioid requirements and opioid-related side effects. However, the effect of the frequency of the electrical stimulus on the postoperative analgesic response to TENS therapy has not been studied. METHODS: One hundred women undergoing major gynecological procedures with a standardized general anesthetic technique were enrolled in the study. Patients were randomly assigned to four groups: group I, patient-controlled analgesia (PCA) plus sham TENS (no stimulation); group II, PCA plus low-frequency (2-Hz) TENS; group m, PCA plus high-frequency (100-Hz) TENS; group IV, PCA plus mixed-frequency (2- and 100-Hz) TENS. The PCA device was programmed to deliver 2-3 mg intravenous boluses of morphine with a lockout interval of 10 min. The TENS device was used every 2 h during the day. Standard 100-mm visual analog scales were used to assess pain, sedation, fatigue, and nausea at specific intervals after surgery. RESULTS: Mixed frequency (2 and 100 Hz) of stimulation decreased morphine requirements by 53% compared with the sham group; low (2-Hz) and high (100-Hz) frequencies produced 32% and 35% decreases, respectively. All three "active" TENS groups reduced the duration of PCA therapy, as well as the incidence of nausea, dizziness, and itching. CONCLUSIONS: TENS decreased postoperative opioid analgesic requirements and opioid-related side effects when utilized as an adjunct to PCA after lower abdominal surgery. Use of TENS at mixed (2- and 100-Hz) frequencies of stimulation produced a slightly greater opioid-sparing effect than either low (2-Hz) or high (100 Hz) frequencies alone. (+info)
Payer cost savings with endometrial ablation therapy.
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CONTEXT: Dysfunctional uterine bleeding (DUB) is a significant cost burden for payers in the US healthcare system because hysterectomy, the common curative treatment, is associated with high hospitalization costs. OBJECTIVE: To determine the potential economic benefit to payers of endometrial ablation as an alternate treatment for the benign DUB disorder. STUDY DESIGN: A retrospective analysis of healthcare claims including the total direct costs to the payer (reimbursement) and patient (copayment). The study was designed to capture all DUB-related claims costs for the entire episode of care from initial diagnosis through follow-up care for 12 months postprocedure. PATIENTS AND METHODS: Twenty-four months of claims data from premenopausal women aged 25 to 50 years enrolled in a large managed care organization were screened based on relevant diagnostic and procedural codes. Incidence and costs of hysterectomy and ablation were determined, and potential payer savings were calculated based on hypothetical hysterectomy-to-ablation conversion rates of 25% to 50%. RESULTS: By performing ablation in lieu of hysterectomy for DUB, an average per-case savings of approximately $4,300 is possible. Potential annual payer savings are approximately $515,000 and $1.03 million for a 1-million-member plan, based on the 25% and 50% conversion rates, respectively. The recently approved uterine balloon therapy ablation technique could be instrumental in overcoming current barriers to wider utilization of ablation surgery. CONCLUSION: If ablation is used in lieu of hysterectomy when medically appropriate, a payer organization could reduce the cost of treating patients with DUB who are not responsive to drug therapy or dilation and curettage alone. Our data suggest that hysterectomy is the most common surgical therapy for this disorder, even though the less invasive endometrial ablation approach is more consistent with accepted DUB treatment guidelines. Payers therefore have an economic incentive to adopt guidelines and reimbursement policies that promote ablation therapy for DUB. (+info)
Combined epidural-spinal opioid-free anaesthesia and analgesia for hysterectomy.
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Postoperative nausea and vomiting (PONV) are major problems after gynaecological surgery. We studied 40 patients undergoing total abdominal hysterectomy, allocated randomly to receive opioid-free epidural-spinal anaesthesia or general anaesthesia with continuous epidural bupivacaine 15 mg h-1 or continuous bupivacaine 10 mg h-1 with epidural morphine 0.2 mg h-1, respectively, for postoperative analgesia. Nausea, vomiting, pain and bowel function were scored on 4-point scales for 3 days. Patients undergoing general anaesthesia had significantly higher nausea and vomiting scores (P < 0.01) but significantly lower pain scores during rest (P < 0.05) and mobilization (P < 0.01). More patients undergoing general anaesthesia received antiemetics (13 vs five; P < 0.05), but fewer received supplementary opioids on the ward (eight vs 16; P < 0.05). We conclude that opioid-free epidural-spinal anaesthesia for hysterectomy caused less PONV, but with less effective analgesia compared with general anaesthesia with postoperative continuous epidural morphine and bupivacaine. (+info)