Andrew J. Walter

Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology.

Vaginal hysterectomy fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effectiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterectomy. Strategies to improve resident training and promote collaboration and referral among practicing physicians and increasing awareness of evidence supporting vaginal hysterectomy can improve the primary use of this hysterectomy approach.

Every woman deserves a high-volume gynecologic surgeon

&NA; Most women undergoing hysterectomy in the United States have their surgery performed by a low‐volume gynecologic surgeon. Evidence supports that, when compared to patients operated on by high‐volume surgeons, these women have worse outcomes including fewer minimally invasive procedures and increased rates of complications. The factors that promote low‐volume surgeons and suggestions for how to change this are reviewed in this Viewpoint.

Adverse events associated with pelvic organ prolapse surgeries that use implants.

OBJECTIVE: To estimate the rate of vaginal implant exposure associated with biologic grafts and permanent mesh used for pelvic organ prolapse (POP) surgery, to describe treatments used for these complications, and to estimate response rates to these treatments. The secondary aims were to describe the operative and perioperative complications. METHODS: This was a retrospective analysis of female members of Kaiser Permanente Southern and Northern California and Hawaii who underwent POP surgeries with biologic grafts and permanent mesh between September 2008 and May 2010. Inpatient and outpatient electronic medical records were reviewed for postoperative adverse events. RESULTS: During the 21-month period, 1,282 women, mean age of 62 years (±10 standard deviation), median parity of 3 (interquartile range 2–4), and median body mass index of 28 (interquartile range 24–30) underwent prolapse repairs with 1,484 implants with a mean follow-up time of 358 days (±276 standard deviation). Vaginal exposures occurred more often with permanent mesh (53/847 [6%]) than biologic grafts (10/637 [1.6%]) (P<.001). Resolution of vaginal exposure after the first treatment occurred in 24 of 63 (38%), whereas 39 of 63 (62%) required multiple treatments. Surgical excision was performed in 20 of 63 (32%) exposures. Permanent mesh exposures were more likely to require surgical excision (20/53 [38%]) than biologic graft exposures (zero of 10) (P=.02). CONCLUSION: Vaginal exposure occurred more frequently with permanent mesh than biologic graft, may require multiple treatments, and occasionally require surgical excision. LEVEL OF EVIDENCE: II

Variability of Reported Techniques for Performance of the Pubovaginal Sling Procedure

Abstract: The aim of this study was to determine the commonly used techniques for sling surgery. A questionnaire was distributed to the attendees at the 20th Annual Scientific Meeting of the American Urogynecologic Society. Techniques addressed included the type and length of the graft material, the fixation point, and the methods of sling tensioning. Type of training and monthly surgical volume was also determined. Sixty-five gynecologic and urologic surgeons responded to the survey, the majority of whom were fellowship-trained urogynecologists (68%). The median monthly operative experience was 8 anti-incontinence procedures, including 3.5 pubovaginal slings. There was wide inter-respondent variability in all techniques except fixation point. There was also large intra-respondent variability in sling technique: 42% reported the use of differing graft materials, 19% noted using differing graft lengths, and 19% employed variable tensioning methods. Type of training and operative experience did not predict surgical technique(s) or consistency. Our conclusion was that there is wide variability in the techniques of sling performance.

Minimally Invasive Hysterectomy and Power Morcellation Trends in a West Coast Integrated Health System

OBJECTIVE To examine trends in minimally invasive hysterectomy and power morcellation use over time and associated clinical characteristics. METHODS We conducted a trend analysis and retrospective cohort study of all women 18 years of age and older undergoing hysterectomy for benign conditions at Kaiser Permanente Northern California collected from electronic health records. Generalized estimating equations and Cochran-Armitage testing were used to assess the primary outcomes, hysterectomy incidence, and proportion of hysterectomies by surgical route and power morcellation. Logistic regression analysis was used to assess secondary outcomes, clinical characteristics, and complications associated with surgical route. RESULTS There were 31,971 hysterectomies from 2008 to 2015; the incidence decreased slightly from 2.86 (95% confidence interval [CI] 2.85-2.87) to 2.60 (95% CI 2.59-2.61) per 1,000 women (P<.001). Minimally invasive hysterectomies increased from 39.8% to 93.1%, almost replacing abdominal hysterectomies entirely (P<.001). Vaginal hysterectomies decreased slightly from 26.6% to 23.4% (P<.001). The proportion of nonrobotic laparoscopic hysterectomies with power morcellation increased steadily from 3.7% in 2008 to a peak of 11.4% in 2013 and decreased to 0.02% in 2015 (P<.001). Robot-assisted laparoscopic hysterectomies remained a small proportion of all hysterectomies comprising 7.8% of hysterectomies in 2015. Women with large uteri (greater than 1,000 g) were more likely to receive abdominal hysterectomies than minimally invasive hysterectomy (adjusted relative risk 11.62, 95% CI 9.89-13.66) and laparoscopic hysterectomy with power morcellation than without power morcellation (adjusted relative risk 5.74, 95% CI 4.12-8.00). Laparoscopic supracervical hysterectomy was strongly associated with power morcellation use (adjusted relative risk 43.89, 95% CI 37.55-51.31). CONCLUSION A high minimally invasive hysterectomy rate is primarily associated with uterine size and can be maintained without power morcellation.

Percutaneous bone anchor sling using synthetic mesh associated with urethral overcorrection and erosion.

Abstract: Percutaneous bone anchor bladder neck suspension has been recommended as a less morbid alternative to traditional anti-incontinence procedures. Specifically, it has reported to be associated with shorter duration of hospitalization, catheterization and urinary retention, and equivalent short-term cure rates. Recently, there have been reports of pubic osteomyelitis associated with bone anchor placement, and high incidences of recurrent incontinence. To improve the effectiveness of the procedure the placement of a suburethral synthetic collagen-impregnated mesh without tension was recommended. A specific device is included with the kit (Suture Spacer (Microvasive/Boston Scientific Corp., Natick, MA)) to prevent overcorrection of the urethrovesical junction. We present a case of urethral erosion and complete urinary retention secondary to use of a percutaneous bone anchor sling using a ProteGen mesh (Microvasive/Boston Scientific Corp., Natick, MA). Significant postoperative urethral overcorrection was noted despite intraoperative use of the Suture Spacer.

Why do we argue about route of hysterectomy? A call for dialogue

As part of the Presidential Address given at the 42nd Annual Scientific Meeting of the Society of Gyneocologic Surgeons, I made a call for a national dialogue to increase the rate of vaginal hysterectomy to at least 40%. I admit this number is arbitrary and is based upon an internal review of hysterectomies performed at The Permanente Group North Valley. Data revealed that about one half of patients were vaginally parous, had no suspicion for adnexal pathology, and had a uterus <12 weeks in size—technically the most straightforward candidates for vaginal hysterectomy. Doing 80% of these patients via the vaginal route would translate to a vaginal hysterectomy rate of 40%. In addition, cases series and randomized controlled trials (from USA and international authors) confirm that this higher rate is feasible [1–4]. Level 1 evidence shows that vaginal hysterectomy is associated with reduced costs and equal to or reduced morbidity rates when compared with all other routes of hysterectomy. This evidence has led the American Congress of Obstetricians and Gynecologists to recommend vaginal hysterectomy whenever technically feasible [5, 6]. Despite this data and support, vaginal hysterectomy has never constituted >20% of the total hysterectomies in the USA, and current use patterns suggest that rates are in decline, parallel with increased use of the more expensive endoscopic (predominately robotic) approaches [7–9]. Even though abdominal hysterectomy rates are also finally in decline, why is it that neither in the past nor currently has there been general concern that vaginal hysterectomy rates have been so low compared with rates determined to be feasible, especially in this era of constrained resources? I have asked this question and have received a number of reasonable responses; I will highlight two:

Laparoscopic versus open Burch retropubic urethropexy: Comparison of morbidity and costs when performed with concurrent vaginal prolapse repairs

OBJECTIVE The purpose of this study was to determine the morbidity and cost that are associated with laparoscopic and open Burch retropubic urethropexy when they are performed with concurrent vaginal prolapse repairs. STUDY DESIGN We conducted a retrospective study of all patients who had undergone laparoscopic (n = 76) or open (n = 143) Burch retropubic urethropexy with at least 1 concurrent vaginal repair for symptomatic prolapse. We compared demographic data, level of prolapse, operative and postoperative details, medical and surgical histories, complications, and hospital charges. RESULTS The group with open retropubic urethropexy had an older age, greater degree of prolapse, fewer concurrent hysterectomies, and a greater number of vaginal procedures than the group with laparoscopic retropubic urethropexy. There were minimal differences in complications and no differences in the estimated blood loss, operative time, hemoglobin change, hospitalization, or hospital charges between the 2 groups. CONCLUSION Traditional benefits of laparoscopic retropubic urethropexy were not apparent when vaginal prolapse repairs were performed.