Ozgur H. Harmanli

Hysterectomy in obese women: a comparison of abdominal and vaginal routes.

OBJECTIVE: To compare perioperative outcome measures of abdominal and vaginal hysterectomies in obese women. METHODS: We reviewed the charts of all obese women (body mass index more than 30 kg/m2) who underwent abdominal or vaginal hysterectomy for benign gynecologic conditions in our institution between 1997 and 2002. Laparoscopically assisted vaginal hysterectomies and hysterectomies with concomitant major pelvic or abdominal surgery were excluded. The rate of operative and postoperative complications, length of hospitalization, operative time, and perioperative change of hemoglobin concentration were analyzed for abdominal hysterectomy and vaginal hysterectomy. RESULTS: The study group consisted of 369 obese women, of whom 189 (51.2%) underwent abdominal, and 180 (48.8%), vaginal hysterectomy. Patient characteristics were statistically comparable between the groups except for uterine weight, which was higher in the abdominal group, and parity, which was greater for women who underwent vaginal hysterectomy (P < .05). After controlling for all the significantly different variables, vaginal hysterectomy resulted in lower incidence of postoperative fever (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.12–0.39), ileus (OR 0.21, 95% CI 0.06–0.75), urinary tract infection (OR 0.21, 95% CI 0.06–0.75), shorter operative time (126.8 ± 58.7 minutes compared with 109.7 ± 68.5 minutes) and length of hospital stay (3.5 ± 1.9 days compared with 1.9 ± 1.1 days). Seven women (3.7%) who underwent abdominal hysterectomy developed wound infections during their hospital stay compared with none in the vaginal hysterectomy group. CONCLUSION: For obese women, vaginal hysterectomy is superior due to its lower incidence of postoperative fever, ileus, and urinary tract infection and shorter operative time and hospital stay. LEVEL OF EVIDENCE: II-2

Is prior uterine surgery a risk factor for adenomyosis

OBJECTIVE: The objective of our study was to assess whether prior uterine surgery is a risk factor for adenomyosis. METHODS: Medical records of women who had a hysterectomy for benign conditions between January of 1995 and June of 2002 were reviewed. Women with and without adenomyosis were compared with respect to history of prior uterine surgery, such as cesarean delivery, myomectomy, endometrial ablation, dilation and evacuation, and dilation and curettage. RESULTS: Of 873 completed records available, 412 patients (47.1%) had adenomyosis. Mean age and race distribution were similar between the 2 groups. The group with adenomyosis had significantly higher gravidity (P < .001) and parity (P = .004), but smaller uterine size (P < .001) and uterine weight (P < .001). Univariable analysis for each aforementioned specific surgical procedure did not indicate a significant difference between women with and without adenomyosis. However, history of any prior uterine surgery increased the risk of adenomyosis (48.8% and 41.0%, odds ratio 1.37, 95% confidence interval 1.05–1.79) on univariable analysis. This association remained significant when all of the factors were combined in a multivariable logistic regression model. CONCLUSION: In this study, we found a significantly increased risk of adenomyosis with prior uterine surgery. The absence of significant association with any specific surgical procedure is possibly the result of a smaller number of subjects in each individual group. LEVEL OF EVIDENCE: II-3

Trends in the rate of shoulder dystocia over two decades.

Objective. To describe the trend in the rate of shoulder dystocia over twenty-four years and identify the risk factors related to the occurrence of dystocia. Methods. Data was obtained from Maryland State regarding all vaginal deliveries that occurred during six different time periods at five-year intervals since 1979. Trends in the rate of shoulder dystocia, episiotomy, forceps and vacuum delivery were examined. Results. There were a total of 277 974 vaginal deliveries. The overall rate of shoulder dystocia was 1.29% (n = 3590). Induction of labor (adjusted OR 1.2, 1.1–1.3), presence of diabetes (gestational (OR 1.9, 1.7–2.3) or pre-gestational (OR 3.8, 2.7–5.4)), fetal macrosomia (OR 5.1, 4.1–6.3) use of episiotomy (OR 1.6, 1.5–1.8), forceps (OR 1.3, 1.0–1.8) or vacuum (OR 2.3, 2.0–3.9) at delivery were associated with a higher rate of shoulder dystocia. Trend. There was an increase in the rate of shoulder dystocia from 0.2% in 1979 to 2.11% in 2003. In addition there was a drop in the overall episiotomy rate from 73.67% to 23.94% and increase in the use of vacuum from 0.1% to 8.36%. Conclusion. The rate of shoulder dystocia has increased by 10 fold during the study period. The use of episiotomy either at spontaneous delivery or instrumental delivery does not appear to decrease the occurrence of shoulder dystocia.

Is severe perineal damage increased in women with prior anal sphincter injury

Objective. There is conflicting data in the literature regarding the risk of obstetric anal sphincter laceration in patients with a prior laceration. This retrospective chart review seeks to examine the risk of recurrence of obstetric anal sphincter lacerations. Methods. Patients who sustained anal sphincter laceration at delivery during a 13-year time period from January 1991 to December 2003 were identified from the medical records database at Temple University Hospital. All subsequent deliveries in this group of patients were extracted from the database. Chart review was performed on all subsequent deliveries with specific attention to demographic factors such as age, race, parity, etc., maternal weight, fetal weight, presence of maternal diabetes, and labor characteristics such as induction or augmentation of labor, instrumentation at delivery (vacuum or forceps), use of episiotomy, and degree of perineal laceration. Results. There were 23 451 vaginal deliveries at Temple University Hospital between January 1, 1991 and December 31, 2003. Anal sphincter laceration was noted in 778 subjects. Subsequent deliveries among the group of patients with prior sphincter tears numbered 271. Six (2.4%) patients had recurrence of anal sphincter lacerations, and five of them were third degree lacerations. The rate of recurrent lacerations was not significantly different from the rate of initial lacerations (2.4% vs. 3.3%; odds ratio 0.72, 95% confidence interval 0.33–1.59; p = 0.4). Women who sustained recurrent lacerations were older, more obese (mean weight 92 kg vs. 82 kg), had larger babies (3506 g vs. 3227 g), and were more likely to have episiotomies (66.7% vs. 7%) or instrumental deliveries (33.3 vs. 6.5%). Conclusion. Prior anal sphincter laceration does not result in an increased rate of recurrence. Operative vaginal delivery particularly with episiotomy is a risk factor for both initial and recurrent laceration.

Lidocaine jelly and plain aqueous gel for urethral straight catheterization and the Q-tip test: A randomized controlled trial

OBJECTIVE: To compare the pain perception between lidocaine and plain aqueous gel during assessment of postvoid residual volume and the Q-tip test. METHODS: Patients were randomly assigned to either to 2% lidocaine hydrochloride jelly or plain aqueous gel. The allocated gel was first used to lubricate a catheter that was inserted into the bladder to measure the postvoid residual volume. After removal of the catheter, a cotton swab, coated with the same allocated gel, was advanced to the urethrovesical junction until resistance was felt. The angle of the swab with the horizontal plane was measured at rest and with Valsalva maneuver. Relevant baseline characteristics and the Wong-Baker FACES pain scores (where 0 is for no pain and 5 for worst pain) were compared. RESULTS: After randomization, lidocaine and the plain aqueous gel arms consisted of 69 and 68 women, respectively. Baseline characteristics of the groups were similar. Significantly fewer women in the lidocaine group (62.3%) reported any pain than those allocated to plain aqueous gel (80.9%) (odds ratio 0.39, 95% confidence interval 0.18–0.85). The median pain score was significantly lower in the lidocaine group (1, range 0–5) compared with 2 (range 0–4), P<.001). CONCLUSION: When compared with plain aqueous gel, 2% lidocaine jelly significantly reduces pain perception during evaluation of postvoid residual volume and the Q-tip test. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00883103. LEVEL OF EVIDENCE: I

Vaginal Evisceration During Pessary Fitting and Treatment With Immediate Colpocleisis

BACKGROUND: Complications from pessaries are rare and occur predominantly as a result of neglect and loss to follow-up. We report a case of vaginal evisceration at the time of pessary insertion, which was repaired with concomitant colpocleisis. CASE: An 82-year-old woman with stage IV pelvic organ prolapse (POP) presented for a routine pessary fitting, which resulted in vaginal evisceration and displacement of the pessary into the abdomen. She was treated successfully with immediate colpocleisis after transvaginal removal of the pessary and repair of the rupture site. CONCLUSION: Pessary insertion can result in vaginal evisceration. Both POP and vaginal rupture can be successfully treated with removal of the pessary, closure of the vaginal defect, and LeFort colpocleisis all in one session.

Narrow pubic arch and increased risk of failure for vaginal hysterectomy.

OBJECTIVE: The purpose of this study was to evaluate the risk factors involved in failed vaginal hysterectomies. METHODS: Data on all vaginal hysterectomies performed by a single gynecologic surgeon were collected prospectively. Patients requiring pelvic floor repair were excluded. Any procedure converted to the abdominal approach was classified as a failed vaginal hysterectomy and comprised the study group. For every woman who had a failed vaginal hysterectomy, the next 2 women who had successful vaginal hysterectomies immediately after the failed vaginal hysterectomy were taken as controls. Risk factors such as age, parity, body weight, surgical indication, uterine size, presence of leiomyomata in the anterior lower uterine segment, previous pelvic surgeries, abdominopelvic adhesions, location and length of cervix, narrow pubic arch, intraoperative complications such as bleeding requiring transfusion, visceral injury, nulliparity, and adnexal removal were compared between groups. RESULTS: We compared 25 failed vaginal hysterectomies with 50 controls whose procedures were completed successfully through the vagina. Among all the factors gynecologists can assess preoperatively, only the presence of a narrow pubic arch increased the risk of failure for vaginal hysterectomy (odds ratio [OR] 4.1; 95% confidence interval 1.32–12.69). Intraoperative bleeding with transfusion was also found as an independent cause for conversion to laparotomy (OR 7.37; 95% confidence interval 1.75–31.06). CONCLUSION: Women with a narrow pubic arch are not good candidates for vaginal hysterectomy. The most common unpredictable cause for conversion to laparotomy from the vaginal approach is intraoperative bleeding requiring transfusion. LEVEL OF EVIDENCE: II-2

Vaginal Hysterectomy for the Enlarged Uterus

Objective: To evaluate the effect of uterine weight on the perioperative outcomesof vaginal hysterectomy for benign gynecological conditions. Materials and Methods: The medical records of 312 consecutive women who underwent vaginal hysterectomies for benign gynecological conditions without major pelvic reconstruction at Temple University Hospital between March 1994 and August 1999were reviewed. 88 women with uterine weights ≧250 g were compared with 224 women with uterine weights <250 g. The risk of perioperative complications, operative time, perioperative hemoglobin change, length of postoperative hospital stay, and readmission were evaluated between the groups. Results: Groups were similar with respect to age, parity, history of previous pelvic surgery and concurrent adnexal removal. Operative time was significantly increased for women with uteri weighing ≧250 g. Women with uterine weight ≧250 g had a higher risk for postoperative febrile morbidity. The risks of all other major complications, perioperative change in hemoglobin concentration, length of stay, and readmission risk were not statistically different between the groups (p < 0.05). Conclusions: Despite the increased postoperative febrile morbidity and prolonged operative time, women with uteri weighing ≧250 g who underwent vaginal hysterectomy were discharged from the hospital without any increase in other complications when compared to women with a smaller uterus.

The Negative Predictive Value of "Inadequate" Endometrial Biopsy in Diagnosing Endometrial Neoplasia

Objective: To evaluate the negative predictive value of endometrial samples that were reported as inadequate in diagnosing endometrial hyperplasia or malignancy. Study Design: The negative predictive value of an inadequate office endometrial sample for endometrial neoplasia was determined. Results: Seventy-eight cases were included in the study. Two patients were lost to follow-up. Thirty-seven (48.7%) of 76 women who had complete records had follow-up tissue diagnoses. The negative predictive value of inadequate endometrial biopsy sample in this group was 97.2%. The remaining 39 (51.3%) were followed by clinical examination and/or imaging studies only. When all 76 patients are considered, the negative predictive value of the inadequate endometrial biopsy sample increased to 98.7%. Conclusion: Our findings suggest that an inadequate office endometrial sample may be sufficient to rule out endometrial neoplasia because of its high negative predictive value.

Can We Use a Catheter to Do the Q-Tip Test?

OBJECTIVE: To compare two commonly used modifications to the standard Q-tip test for urethral hypermobility: catheter alone and catheter with Q-tip. METHODS: All women referred for the evaluation of urinary incontinence or pelvic organ prolapse were included in the study. A postvoid residual urine was collected on each patient and the angle of the urethra with the horizontal plane was measured at rest and with Valsalva with the Q-tip, catheter alone, and catheter with Q-tip. The test was considered positive if the angle of excursion was 30 degrees or more. RESULTS: In this group of 100 consecutive women with urinary incontinence or pelvic organ prolapse, the mean change in the angle was significantly different from the standard Q-tip test (51 degrees) when catheter alone (35 degrees, P<.001) or catheter with Q-tip modifications were used (44 degrees, P<.001). This difference was due to a significant reduction in the resting and Valsalva maneuver angles with the catheter alone, and a significant decrease only in the Valsalva maneuver angle with the catheter with Q-tip method (P<.001). The percentage of positive tests for the standard Q-tip test (92%) was significantly different from the catheter only method (63%, P<.001), and from the catheter with Q-tip technique (83%, P=.021). The “best match” values of 10 degrees for the catheter alone, and 15 degrees for the catheter with Q-tip methods produce the best equivalent results at this time. CONCLUSION: The use of a catheter, instead of a Q-tip, in the evaluation of urethral hypermobility resulted in reduced angles of excursion from resting to Valsalva maneuver. LEVEL OF EVIDENCE: III