Kirsten B. Kluivers

Measurement of quality of recovery using the QoR-40: a quantitative systematic review

BACKGROUND Several rating scales have been developed to measure quality of recovery after surgery and anaesthesia, but the most extensively used is the QoR-40, a 40-item questionnaire that provides a global score and subscores across five dimensions: patient support, comfort, emotions, physical independence, and pain. It has been evaluated in a variety of settings, but its overall psychometric properties (validity, reliability, ease of use, and interpretation) and clinical utility are uncertain. METHODS We undertook a quantitative systematic review of studies evaluating psychometric properties of the QoR-40. Data were combined in meta-analyses using random effects models. This resulted in a total sample of 3459 patients from 17 studies originating in nine countries. RESULTS We confirmed content, construct, and convergent [pooled r=0.58, 95% confidence interval (CI): 0.51-0.65] validity. Reliability was confirmed by excellent intraclass correlation (pooled α=0.91, 95% CI: 0.88-0.93), test-retest reliability (pooled r=0.90, 95% CI: 0.86-0.92), and inter-rater reliability (intraclass correlation=0.86). The clinical utility of the QoR-40 instrument was supported by high patient recruitment into evaluation studies (97%), and an excellent completion and return rate (97%). The mean time to complete the QoR-40 was 5.1 (95% CI: 4.4-5.7) min. CONCLUSIONS The QoR-40 is a widely used and extensively validated measure of quality of recovery. The QoR-40 is a suitable measure of postoperative quality of recovery in a range of clinical and research situations.

Risk Factors for Exposure, Pain, and Dyspareunia After Tension-Free Vaginal Mesh Procedure

OBJECTIVE: To identify possible risk factors for exposure, dyspareunia, and pain after insertion of tension-free vaginal mesh in pelvic organ prolapse surgery. METHODS: This was a prospective observational cohort study. Consecutive women who underwent surgery with a trocar-guided tension-free vaginal mesh kit were included and evaluated at 6 weeks and at 6 and 12 months after surgery with respect to anatomy and complications. Logistic regression analysis was performed to identify risk factors for exposure, dyspareunia, and pain. RESULTS: Two hundred ninety-four patients were included. Exposure was found in 34 patients (12%). Smoking and total mesh were risk factors for exposure (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.1–8.7 and OR 3.0, 95% CI 1.2–7.0, respectively). Clinical and surgical experience were inversely related to the risk of exposure (OR 0.5, 95% CI 0.3–0.8 per decade). Pain (OR 3.2, 95% CI 1.2–8.4) and dyspareunia (OR 4.7, 95% CI 1.7–12.8) before surgery were predictive for pain and dyspareunia after surgery, respectively. Pain after surgery was found in 35 out of 275 (13%) patients and dyspareunia was found in 77 out of 171 (45%) patients. CONCLUSION: Smoking, total tension-free vaginal mesh, and experience were predictive factors for mesh exposure. LEVEL OF EVIDENCE: II

The operation room as a hostile environment for surgeons: physical complaints during and after laparoscopy.

Abstract Due to suboptimal ergonomic conditions during laparoscopic procedures, surgeons are exposed to physical strain on the upper extremity. The primary objective of this study was to assess the prevalence of physical complaints among laparoscopic surgeons and to assess the factors that influence these complaints. A questionnaire was distributed in a university hospital to all surgeons who perform laparoscopic procedures. Participants were asked to answer questions related to experience, physical complaints during or after laparoscopic procedures and the possible causes of their complaints. Fifty-five out of 92 (60%) surgeons completed the questionnaire. In this group, 40 surgeons (73%) reported physical complaints during or after laparoscopic procedures, mainly involving neck, lower back, shoulders and thumbs. Significantly more surgeons reported complaints in the dominant upper extremity compared to the non-dominant side. Poor table height adjustment, bad monitor positioning and suboptimal design of instrument handles were reported as important causes of complaints. Physical complaints of the dominant upper extremity are common among laparoscopic surgeons, especially less experienced surgeons. The dominant upper extremity appears to be more involved than the non-dominant side. More awareness and implementation of ergonomic guidelines is needed.

Systematic review on recovery specific quality-of-life instruments

BACKGROUND Postoperative recovery is a considerable issue in studies comparing operative techniques of similar effectiveness. In recent years, a shift has occurred toward patient-centered study outcomes such as quality-of-life questionnaires. The objective of this article is to provide a systematic review of the literature on general postoperative, recovery-specific quality-of-life instruments and their measurement properties. METHODS We searched the databases EMBASE.com, Cinahl, PsycINFO, and PubMed for articles reporting on postoperative, recovery-specific quality-of-life instruments. A checklist was used to assess the revealed studies and instruments. Existing quality criteria were applied to the measurement properties to compare the instruments. RESULTS The search strategy identified 620 studies, of which 18 studies reported on 12 different postoperative, recovery-specific quality-of-life instruments. None of the instruments had been validated completely in line with the 8 quality criteria, which were used to assess the measurement properties. Two instruments were clearly superior, which were the Postdischarge surgical recovery scale and the Quality of recovery-40. CONCLUSIONS No fully validated instrument is available for the assessment of general postoperative recovery. We advise to use the Postdischarge surgical recovery scale and the Quality of recovery-40 in future validation and application studies on short-term postoperative recovery.

Quality of life after laparoscopic and abdominal hysterectomy: a randomized controlled trial.

OBJECTIVE: To report the 4-year follow-up quality-of-life data of a randomized controlled trial between abdominal and laparoscopic hysterectomy and to investigate whether any difference in quality of life would remain long-term. METHODS: Patients scheduled for hysterectomy for benign indications were randomized and received the Dutch version of the Short Form 36 questionnaire. The Short Form 36 consists of eight domains in which 100 points can be obtained. Higher scores denote a higher quality of life. A linear mixed model was used to study the differences between the two groups up to 4 years after surgery for each of the domains and the total Short Form 36 score separately. RESULTS: Fifty-nine patients were randomized (27 to laparoscopic hysterectomy and 32 to abdominal hysterectomy). Median follow-up after surgery was 243 weeks (range, 188–303 weeks). The overall response rate on the Short Form 36 questionnaire after 4 years was 83% (49 of 59 patients). Total Short Form 36 questionnaire scores were significantly higher in patients after laparoscopic compared with abdominal hysterectomy up to 4 years after surgery (overall mean difference 50.4 points [95% confidence interval 1.0–99.7] in favor of laparoscopic hysterectomy). Higher scores were also found on the domains physical role functioning, social role functioning, and vitality. CONCLUSION: With a follow-up of 4 years, patients who underwent laparoscopic hysterectomy reported a better quality of life compared with abdominal hysterectomy. Therefore, patients in whom vaginal hysterectomy is not possible should be able to have a laparoscopic hysterectomy, if feasible, in terms of uterine size. CLINICAL TRIAL REGISTRATION: ISRCTN Register, www.controlled-trials.com/isrctn, ISRCTN15214439. LEVEL OF EVIDENCE: I

Can preoperative urodynamic investigation be omitted in women with stress urinary incontinence? A non-inferiority randomized controlled trial†‡§

To assess in women with stress urinary incontinence (SUI) the value of urodynamics prior to treatment.

Evaluation of the risk of malignancy index in daily clinical management of adnexal masses

OBJECTIVE To verify the effectiveness of the Risk of Malignancy Index in the discrimination between non-invasive (benign and borderline) lesions and invasive malignant adnexal masses in daily clinical practice. METHODS This prospective observational study was conducted in a multicentre cooperation of 11 hospitals. A total of 548 women with adnexal masses were included. Ultrasound characteristics, menopausal status and serum CA 125 level were registered preoperatively, and combined into the RMI afterwards. Final diagnosis was based on routine histopathologic examination. The decision to have patients operated by or with a gynecologic oncologist was based on the clinical impression of the gynecologist in the local hospital, based on physical examination, testing of serum samples, and ultrasound examination. This was compared with the hypothetical situation in which the RMI would have been applied as method of selection. RESULTS An RMI of 200 achieved a sensitivity of 81% and specificity of 85% in the detection of ovarian cancer. Positive and negative predictive values were 48% and 96% respectively. In current practice, 64% of ovarian cancer patients were operated by a gynecologic oncologist. This percentage would have increased to 80% if the RMI with a cutoff value of 200 would have been used as method of selection. CONCLUSIONS In our study population, introduction of the RMI would improve the management of adnexal masses, with a higher percentage of ovarian cancer patients that are operated by a gynecologic oncologist. At the same time, referral of patients with non-invasive (benign and borderline) lesions would be reduced.

A systematic review of clinical studies on dynamic magnetic resonance imaging of pelvic organ prolapse: the use of reference lines and anatomical landmarks

Introduction and hypothesisThe aim of our study was to provide a systematic literature review of clinical studies on pelvic organ prolapse staging with use of dynamic magnetic resonance (MR) imaging.MethodsThe databases EMBASE and PubMed were searched. Clinical studies were included in case they compared pelvic organ prolapse stages as assessed on dynamic MR imaging (using a reference line) with a standardized method of clinical prolapse staging.ResultsTen studies were included, which made use of seven different reference lines in relation to a wide variety of anatomical landmarks.ConclusionOnly few studies have compared pelvic organ prolapse stages as assessed by dynamic MR imaging and clinical examination in a standardized manner. The available evidence suggests that prolapse assessment on dynamic MR imaging may be useful in the posterior compartment, but clinical assessment and dynamic MR imaging seem interchangeable in the anterior and central compartment.

Evaluation of adnexal masses with three-dimensional ultrasonography.

OBJECTIVE: To estimate whether three-dimensional ultrasonography and three-dimensional power Doppler investigation can contribute to the differentiation between benign and malignant ovarian masses. METHODS: Women scheduled for surgical treatment of an adnexal mass were included in a multicenter prospective study. All women underwent two-dimensional and three-dimensional ultrasonographic examination in the week before surgery. All parameters were compared in women with benign tumors, borderline tumors, and malignant tumors using receiver operating characteristic analysis and likelihood ratios. RESULTS: We included 181 women; 144 had a benign mass, 26 had a malignancy, and 11 had a borderline tumor. At three-dimensional ultrasonography, the most striking difference was found in the presence of central vessels in an adnexal mass. Central vessels assessed by three-dimensional ultrasonography were present in 15% (21 of 144) of the benign masses, 69% (18 of 26) of the malignant masses, and 27% (3 of 11) of the masses of borderline malignancy. The likelihood ratios for presence of central vessels for a mass being malignant and/or borderline was 4.9 (95% confidence interval 2.1–12). Mean gray index and flow index were also significantly different between the groups, but other features were not. CONCLUSION: The central localization of vessels in an adnexal mass, as observed by three-dimensional ultrasonography, the mean gray index, and the flow index are potentially important parameters for distinguishing benign from malignant adnexal masses. LEVEL OF EVIDENCE: II-2

The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication

Introduction and hypothesisThe objective of this study is to evaluate cervical amputation with uterosacral ligament plication (modified Manchester) and compare it to vaginal hysterectomy with high uterosacral ligament plication procedure with special regard to the middle compartment.MethodsConsecutive women with pelvic organ prolapse who underwent either vaginal hysterectomy or a modified Manchester procedure were included. Assessments were made preoperatively and at 1-year follow-up, including physical examination with pelvic organ prolapse quantification standardised questionnaires (incontinence impact questionnaire, urogenital distress inventory, and defaecatory distress inventory).ResultsBetween 2002 and 2007, 156 patients were included. Ninety-eight patients returned for a 1-year follow-up. In the modified Manchester group, we found no middle compartment recurrence versus two (4%) in the vaginal hysterectomy group. Anterior and posterior compartment prolapse recurrences (stage ≥2) were similar (approximately 50%). Considering operating time and blood loss, modified Manchester was more favourable. There was no difference in the pre- and postoperative subjective scores. The overall functional outcome was acceptable.ConclusionsWe found an excellent performance of both procedures regarding middle compartment recurrences.