Juha Mäkinen

FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors

BACKGROUND Hysterectomy guidelines highlight an increase in urinary tract injuries with laparoscopic hysterectomy (LH). This national survey analyses complications of LH, abdominal hysterectomy (AH) and vaginal hysterectomy (VH). METHODS A prospective cohort undergoing hysterectomy for benign indications during 2006 was drawn from 53 hospitals in Finland; all communal hospitals participated. Detailed questionnaires covered surgical data and intra- and post-operative major and minor complications, for which risk factors were analysed by a multivariate logistic regression model adjusted for surgical data and patient characteristics. RESULTS Major complications rates in AH (n= 1255, 24%), LH (1679, 32%) and VH (2345, 44%) were 4.0, 4.3 and 2.6%, and total complications rates were 19.2, 15.4 and 11.7%, respectively. Logistic regression showed no statistically significant differences between approaches for any organ injuries or other major complications. Most bladder and bowel injuries (88 and 83%), but not ureter injuries (10%), were recognized intra-operatively. The ureter injury rate was low after LH (0.3%), as it was after other types of hysterectomy. Compared with LH, AH increased the odds of wound infection, and was an independent risk factor for urinary infections and febrile events. Compared with AH, LH and VH both presented a higher risk for pelvic infection; surgically treated equally often regardless of the type of hysterectomy. No differences in complications emerged between LH and VH. Obesity was a risk factor for many infections. Surgical adhesiolysis [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.38-4.21] was the strongest single risk factor for major complications as a whole. Bladder injury was associated with a history of caesarean section (OR 4.01, 95% CI 2.06-7.83) and with a large uterus ≥500 g (OR 2.88, 95% CI 1.05-7.90), while bowel injury was associated with adhesiolysis (OR 29.07, 95% CI 7.17-117.88). CONCLUSIONS FINHYST is a large prospective hysterectomy study illustrating actual complications. Whenever possible, hysterectomy should be minimally invasive.

Finnish national register of laparoscopic hysterectomies: A review and complications of 1165 operations

OBJECTIVE We evaluated the advantages and disadvantages of laparoscopic hysterectomy over a 2-year period when this new technique was introduced to several hospitals in Finland. STUDY DESIGN A nationwide register was founded and a prospective multicenter survey of 1165 laparoscopic hysterectomies was carried out from January 1993 to December 1994. The operations were performed because of uterine fibroids (54%), menorrhagia (27%), dysmenorrhea (8%), endometriosis (2%), and other reasons (9%) by 68 gynecologists at 30 hospitals. RESULTS The mean operation time was 132 minutes. The patients stayed in hospital for an average of 3.3 days, and the mean convalescence period was 17.9 days, half that after abdominal hysterectomy. Complications occurred in 10.2% of the procedures: infections in 5.6%, vascular complications in 1.2%, urinary tract complications in 2.7%, and bowel complications in 0.4%. CONCLUSIONS Laparoscopic hysterectomy offers a short hospital stay and convalescence time to the patient, but effective teaching is imperative to minimize, in particular, the risk of urinary tract injuries.

Screening for endometrial cancer in asymptomatic postmenopausal women with conventional and colour Doppler sonography.

Objective To evaluate endometrial thickness and uterine arterial flow measurement as predictors of endometrial cancer.

One-year cohort of abdominal, vaginal, and laparoscopic hysterectomies : Complications and subjective outcomes

BACKGROUND In the past decade, changes in operative approaches to hysterectomy have resulted in needs to renew study of postoperative morbidity. STUDY DESIGN This prospective observational study, performed in a university teaching hospital in Finland, was conducted to determine the overall number of complications and subjective outcomes after hysterectomy for benign conditions. The population studied during a 1-year period consisted of 687 women, who underwent 516 abdominal hysterectomies, 105 vaginal hysterectomies, and 66 laparoscopic hysterectomies. Complications arising within 1 year of operations were recorded, and subjective complaints and outcomes were assessed using two questionnaire-based evaluations, the first following a convalescence period of 4 to 6 weeks, the second after 1 year. RESULTS Intraoperative complications occurred in 16 patients (2.3%), in 9 patients in the abdominal hysterectomy group (1.7%), and in 4 (3.9%) and 3 patients (4.5%) in the vaginal and laparoscopic hysterectomy groups, respectively. During the hospital stay postoperative complications were found in 28.5% of patients, in the vaginal hysterectomy group (41.9%) more often than in the abdominal and laparoscopic hysterectomy groups (28.3% and 9.1%, respectively). Postoperative infection, including urinary infection, was the main problem, during both the stay in the hospital and the convalescence period at home. It was also the principal reason for readmission to the hospital. Despite an increase in incidence of subjective complaints, from 14.9% during the first evaluation to 37.0% during the second (p < 0.001), 95% of respondents remained satisfied with their operation after 1 year. CONCLUSIONS Vaginal hysterectomy was more often associated with some adverse event, mainly postoperative infection, than abdominal and laparoscopic hysterectomy. Subjective outcomes were not influenced by the type of hysterectomy. Most patients were satisfied with the operation on both short- and longterm followup.

Histological changes in the vaginal connective tissue of patients with and without uterine prolapse

SummaryThe histological structure of the vaginal fascia was studied in two groups of patients: 10 consecutive women having a vaginal repair for uterine prolapse or descent and 10 consecutive women having an abdominal hysterectomy for fibroids. Abnormal histological changes were found in 7 out of 10 patients with uterine descent as compared to 2 out of 10 controls (P < 0.05). This suggests a correlation between histological changes in vaginal connective tissue and pelvic laxity.

FINHYST 2006—national prospective 1-year survey of 5 279 hysterectomies

BACKGROUND In Finland, the number of hysterectomies during one decade has decreased by 34%. The national prospective FINHYST study in 1996 showed abdominal hysterectomy (AH) as being most common: 58%. In Finland since 2002, vaginal hysterectomy (VH) has been most preferred, with laparoscopic hysterectomy (LH) surpassing AH in 2005. METHODS FINHYST 2006 is a national prospective hysterectomy study in which all hospitals collaborated from 1 January to 31 December 2006. Questionnaires, completed by gynaecologists, covered their experience, patient characteristics and surgical data. RESULTS The 5279 hysterectomies distributed by approaches were 44% VHs, 32% LHs and 24% AHs. Less than 2% were subtotal. The main indications for hysterectomy were myomas (33%), uterine prolapse (28%) and menorrhagia (21%). The main indication for VH was not related to uterine prolapse in 39%. Bilateral salpingo-ooforectomy was performed in 36% of AHs, 32% of LHs and 2% of VHs. Antibiotic prophylaxis was used in 97%, and thrombosis prophylaxis in 65%. Haemorrhage was least and operation time shortest with VH, and hospital stay and sick leave were shortest after LH. CONCLUSIONS In Finland, less invasive approaches comprise 76% of hysterectomies. This trend has resulted nationally in shortening of hospital stay and of convalescence time.

Long-term effects of hormone replacement therapy on the uterus and on uterine circulation

OBJECTIVE Our purpose was to study the effects of postmenopausal hormone replacement therapy on the uterus and uterine circulation. STUDY DESIGN The study population consisted of 432 women, 58 to 59 years of age. Color Doppler ultrasonography with a transvaginal probe was used to measure the size of the uterus and the uterine artery pulsatility index. RESULTS The mean endometrial thickness in group 1 (controls without hormone replacement therapy) was significantly thinner compared with group 2 hormone replacement therapy and with group 3 after discontinuance of hormone replacement therapy. The mean uterine artery pulsatility index was lower both in group 2 and 3 compared with group 1. When hormone replacement therapy was initiated 2 to 10 years after menopause, the endometrial thickness did not differ from that among those who had started hormone replacement therapy earlier, but the pulsatility index was significantly higher. There was positive correlation between the size of the uterus and the pulsatility index in group 1, but the correlation was negative in group 2. In general, the duration of hormone replacement therapy had no effect on the pulsatility index. Estrogen users had a significantly thicker endometrium compared with estrogen-progestogen users. The pulsatility index was highest in the estrogen users with progestogen added every month. CONCLUSION The duration, onset of treatment in relation to menopause, discontinuance of hormone replacement therapy, and mode of treatment modify both the normal postmenopausal endometrial thickness and the uterine vascular resistance.

Incarcerated Richter's hernia after laparoscopy: a case report

An unusual case of Richters hernia on the 5th day after laparoscopy is presented. The complaints simulated a postoperative hematoma, but they became so intense that the expansion was surgically explored: a conservative procedure on the loop of small bowel was possible. To prevent this complication after laparoscopy careful shaking of the abdominal wall at removal of the instruments is necessary.

Tubal patency and fertility outcome after expectant management of ectopic pregnancy.

OBJECTIVE To study tubal patency and fertility outcome of patients with expectantly managed ectopic pregnancy (EP). DESIGN A prospective study. SETTING Department of Obstetrics and Gynecology, Turku University Central Hospital, Turku, Finland. PATIENT(S) Thirty patients who wanted to become pregnant again were treated successfully by expectant management of EP. INTERVENTION(S) Patients were examined with posttreatment hysterosalpingography, and they filled out a questionnaire about their subsequent pregnancies. MAIN OUTCOME MEASURE(S) Free passage through open lumen showing tubal patency; number of full-term pregnancies and EPs revealing relative rate of subsequent fertility. RESULT(S) A free passage through the diseased tube was seen in 93% of the cases (28 of 30). Two of the 24 patients (8.4%) who wanted to become pregnant had an obstruction in the diseased tube. One (4.2%) of them had a normal opposite tube and later had a normal pregnancy. The other (4.2%) had an obstruction in both tubes and subsequently had a repeat EP. One of the 6 patients had an EP (this patient did not want to become pregnant and did not use contraception). However, her posttreatment hysterosalpingography was normal. In total, the subsequent pregnancy rate was 88% (21 of 24), and the rate of repeat EP was 4.2% (1 of 24). CONCLUSION(S) Patients who are treated with expectant management have a good long-term fertility outcome. Spontaneous regression of EP does not lead to increased harm or damage to the tube, i.e., the risk for repeat EP is low.

Collagen synthesis in the vaginal connective tissue of patients with and without uterine prolapse

The insufficiency of connective tissue in pelvic relaxation was studied in five patients with uterine descent and in five age-related controls. Samples from vaginal fascias were first studied by histology. Fibroblast cultures started from each sample were analysed for their collagen synthesis and content of type I procollagen messenger RNAs (mRNAs). The cellularity of the fascias in histological specimens and the biosynthesis of collagen in fibroblast cultures decreased with increasing age in both groups. Fibroblasts grown from patients with uterine descent exhibited rates of collagen synthesis similar to or slightly higher than those from age-matched controls. The histological and biochemical changes observed in connective tissue of uterine descent are most likely related to the age and hormonal status of the patients. The findings suggest that uterine descent is not related to defects in the capacity of vaginal fibroblasts to synthesize or process procollagen.