Michael P. Aronson

Avoiding serious infections associated with abdominal hysterectomy: A meta-analysis of antibiotic prophylaxis

OBJECTIVE Our objective was to determine whether the use of preoperative antibiotics prevents serious infections associated with total abdominal hysterectomy. STUDY DESIGN We identified 25 randomized controlled trials of antibiotic prophylaxis that used rigorous protocols. We performed meta-analysis and cumulative meta-analyses for all of the trials, and then we performed separate meta-analysis for cefazolin, metronidazole, and tinidazole. RESULTS Overall, 21.1% (373 of 1768) of the patients who did not receive antibiotic prophylaxis had serious infections after abdominal hysterectomy. Among patients who received any antibiotics, we found that 9.0% (166/1836) had serious postoperative infections; among those who received cefazolin, metronidazole, or tinidazole, 11.4% (70 of 615), 6.3% (17 of 269), and 5.0% (5 of 101), respectively, had serious postoperative morbidity. The differences in the prevalence of infection between women who received prophylaxis and women who did not receive prophylaxis were statistically significant (any antibiotics, p = 0.00001; cefazolin, p = 0.00021; metronidazole, p = 0.015; and tinidazole, p = 0.034). CONCLUSION Because preoperative antibiotics are highly effective in the prevention of serious infections associated with total abdominal hysterectomy, we believe they should be used routinely. In addition, we believe that the use of controls who receive no treatment is no longer justified in trials of antibiotic prophylaxis for total abdominal hysterectomy.

Periurethral and paravaginal anatomy: An endovaginal magnetic resonance imaging study☆

Abstract OBJECTIVE: Endoluminal and phased-array coil techniques both improve the resolution of magnetic resonance imaging. This descriptive study combined these techniques to image the female periurethal and paravaginal anatomy. STUDY DESIGN: Four continent nulliparous women and four incontinent women with bladder neck descent or paravaginal support defects were studied with a 1.5 T magnetic resonance imaging unit by use of a vaginally placed endoluminal coil coupled to a pelvic phased-array coil. RESULTS: The posterior pubourethral ligaments and paravaginal attachments were effectively imaged. Images correlated with clinically appreciated paravaginal defects. A trend toward doubling of the volume of the retropubic space was seen in the incontinent group compared with the continent group. Distances from the posterior symphysis to the anterior vaginal wall were not significantly different between groups. CONCLUSION: An endovaginally placed colon coil coupled to a pelvic phased-array coil allows detailed magnetic resonance imaging of the periurethral and paravaginal anatomy.

Anatomy of anal sphincters and related structures in continent women studied with magnetic resonance imaging

Five anally continent nulliparas of reproductive age were studied with magnetic resonance imaging. The internal and external anal sphincters could be easily delineated, as could the intervening longitudinal musculature, puborectalis muscle, anococcygeal raphe, anorectal lumen, vagina, uterus, bladder, urethra, coccyx, and pubis. The shape of the sphincters was nearly cylindrical, with an anterior component averaging 18.3 mm thick and 28.0 mm long. Fifty-four percent of this anterior thickness was attributable to the internal sphincter. The anorectal angle varied considerably, with a mean of 86.8 +/- 19.1 degrees (range 60-112). The angle between the portion of the rectal lumen supported by the anococcygeal raphe, or levator plate, and the plane of the puborectalis muscle was consistent at 149.0 +/- 6.3 degrees (138-154). The finding of anterior anal sphincters with substantial thickness and length contrasts markedly with a view often pictured in the literature of a female anal sphincter that narrows anteriorly to half its posterior length and forms a small bundle of muscle rather than a broad band. Knowledge of these relationships is important in primary repair of obstetric sphincter lacerations as well as in surgical correction of anal incontinence.

Myomectomy fever: testing the dogma

OBJECTIVE To test the hypothesis that elevated temperature is more common after abdominal myomectomy than after hysterectomy. DESIGN Retrospective cohort study. SETTING Academic medical center. PATIENT(S) One hundred one women who underwent abdominal myomectomy and 160 women who underwent total abdominal hysterectomy for benign disease from 1988-1993. INTERVENTION(S) Abdominal myomectomy. MAIN OUTCOME MEASURE(S) Temperature of > or = 38.5 degrees C within 48 hours after operation. RESULT(S) Although univariate analysis showed that the incidence of elevated temperature was slightly greater among patients who underwent myomectomy (33% versus 26%, relative risk 1.29, 95% confidence interval 0.88-1.90), multivariate logistic regression analysis showed a 3.29 relative risk of elevated temperature (95% confidence interval 1.56-6.96) with myomectomy after controlling for age, parity, estimated blood loss, and treatment by the general gynecology service. CONCLUSION(S) After controlling for confounders, myomectomy was found to be an independent predictor for fever in the first 48 hours after operation.

Use of Prophylactic Tinidazole to Avoid the Serious Infections Associated with Total Abdominal Hysterectomy

Robert Mittendorf’, MD, DrPH, Michelle A. Williams2, ScD, Michael P. Aronson’, MD, Robert E. Berry3, MD, Bruce Kupelnick4, BA and Thomas C . Chalmers‘, MD Deportment of Obstetrics and Gynecology: The University of Chicago, Chicago Lying-in Hospital, Chicago, Illinois, Department of Epidemiology2, School of Public Health, University of Washington, Seattle, Washington, Tufts University School of Medicine’, Boston, Massachusetts and Technology Assessment Group‘, ffarvard School of Public Health, Boston, Massachusetts