Rikke Guldberg

Salpingectomy as standard at hysterectomy? A Danish cohort study, 1977–2010

Objective To assess if the risk of first-time salpingectomy was affected by prior hysterectomy with retained fallopian tubes and by prior sterilisation. Design A historical cohort study. Setting Denmark. Participants 170 000 randomly selected women born 1947–1963 (10 000/year) were followed from 1977 until the end of 2010. Main outcome measures Effect of hysterectomy with retained fallopian tubes or sterilisation on the risk of salpingectomy. Both were modelled in a Cox proportional hazards model as time-dependent covariates, analysing time to first salpingectomy. End of follow-up period was 31 December 2010. Results Of 9591 hysterectomies, 6456 (67.3%) had both fallopian tubes retained. HRs for salpingectomy after hysterectomy with retained fallopian tubes and sterilisation were 2.13 (95% 1.88 to 2.42) and 2.42 (2.21 to 2.64), as compared with those for non-hysterectomised and non-sterilised women. Conclusions Women undergoing hysterectomy with retained fallopian tubes or sterilisation have at least a doubled risk of subsequent salpingectomy. Removal of the fallopian tubes at hysterectomy should therefore be recommended.

Predictors of mortality within 1 year after primary ovarian cancer surgery: a nationwide cohort study

Objectives To identify predictors of mortality within 1 year after primary surgery for ovarian cancer. Design Prospective nationwide cohort study from 1 January 2005 to 31 December 2012. Setting Evaluation of data from the Danish Gynaecology Cancer Database and the Danish Civil Registration System. Participants 2654 women who underwent surgery due to a diagnosis of primary ovarian cancer. Outcome measures Overall survival and predictors of mortality within 0–180 and 181–360 days after the primary surgery. Examined predictors were age, preoperative American Society of Anesthesiologists (ASA) score, body mass index (BMI), International Federation of Gynaecology and Obstetrics (FIGO) stage, residual tumour tissue after surgery, perioperative blood transfusion and calendar year of surgery. Results The overall 1-year survival was 84%. Within 0–180 days after surgery, the 3 most important predictors of mortality from the multivariable model were residual tumour tissue >2 cm versus no residual tumour (HR=4.58 (95% CI 3.20 to 6.59)), residual tumour tissue ≤2 cm versus no residual tumour (HR=2.50 (95% CI 1.63 to 3.82)) and age >64 years versus age ≤64 years (HR=2.33 (95% CI 1.69 to 3.21)). Within 181–360 days after surgery, FIGO stages III–IV versus I–II (HR=2.81 (95% CI 1.75 to 4.50)), BMI<18.5 vs 18.5–25 kg/m2 (HR=2.08 (95% CI 1.18 to 3.66)) and residual tumour tissue >2 cm versus no residual tumour (HR=1.84 (95% CI 1.25 to 2.70)) were the 3 most important predictors. Conclusions The most important predictors of mortality within 1 year after surgery were residual tumour tissue (0–180 days after surgery) and advanced FIGO stage (181–360 days after surgery). However, our results suggest that the surgeon should not just aim at radical surgery, but also pay special attention to comorbidity, nutritional state, age >64 years and the need for perioperative blood transfusion.

Synechia vulvae – an unusual cause of urinary symptoms in a 15-year-old girl

A girl, aged 15, menarche aged 13, cycle 7/5 6 weeks, and virgin, was admitted to hospital, because she had difficulties in micturition. During micturition, she had to use two fingers against the perineum to urinate, otherwise only drops came out. She also had the feeling of something filling in her vagina at the size of a tennis ball. Micturition was prolonged (10 15 min). She felt that she was urinating through vagina. After micturition, there was continuous urinary leak. The symptoms increased during menstruation, because blood and tissue clotted the little opening in the perineum. The symptoms started 6 months prior to her admittance to our department. During these 6 months, she was more and more disabled. She drank as little as possible to avoid micturition. She urinated three to four times per day. No nycturia was examined. Her mother confirmed that there had not been symptoms earlier and no history regarding infections. She had never noticed the synechia vulvae during her daughter’s childhood. Gynecologic examination revealed a membrane at the vaginal orifice, but neither the introitus nor the urethral opening could be visualized. There was a small opening where urine could pass through (Figure 1). Abdominal ultrasound showed normal uterus and normal ovaries. Residual urine volume was 40 ml. The ultrasound examination of the kidneys was normal. Urine examination showed no bacterial growth on culture. Under general anesthesia, the obstructing vaginal membrane was incised. The two edges were sutured to prevent a new agglutination (Figure 2). Inspection showed a normal vagina, although it was deep and wide. The portio was normal. The uterus was normal in size and anteverted by exploration. She was instructed to wash the external genitalia after micturition and use lidocaine ointment, if she needed to. After 2 months follow up, gynecologic examination showed a normal introitus of the vagina and no agglutination had occurred. She had no difficulties in micturition.

Risk factors and between-hospital variation of caesarean section in Denmark: a cohort study

Objectives The aim of this study was to estimate the effects of risk factors on elective and emergency caesarean section (CS) and to estimate the between-hospital variation of risk-adjusted CS proportions. Design Historical registry-based cohort study. Settings and participants The study was based on all singleton deliveries in hospital units in Denmark from January 2009 to December 2012. A total of 226 612 births by 198 590 mothers in 29 maternity units were included. Primary and secondary outcome measures We estimated (1) OR of elective and emergency CS adjusted for several risk factors, for example, body mass index, parity, age and size of maternity unit and (2) risk-adjusted proportions of elective and emergency CS to evaluate between-hospital variation. Results The CS proportion was stable at 20%–21%, but showed wide variation between units, even in adjusted models. Large units performed significantly more elective CSs than smaller units, and the risk of emergency CS was significantly reduced compared with smaller units. Many of the included risk factors were found to influence the risk of CS. The most important risk factors were breech presentation and previous CS. Four units performed more CSs and one unit fewer CSs than expected. Conclusion The main risk factors for elective CS were breech presentation and previous CS; for emergency CS they were breech presentation and cephalopelvic disproportion. The proportions of CS were stable during the study period. We found variation in risk-adjusted CS between hospitals in Denmark. Although exhaustive models were applied, the results indicated the presence of systematic variation between hospital units, which was unexpected in a small, well-regulated country such as Denmark.

Use of antibiotics for urinary tract infection in women undergoing surgery for urinary incontinence: a cohort study

Objective To describe the use of antibiotics for urinary tract infection (UTI) before and after surgery for urinary incontinence (UI); and for those with use of antibiotics before surgery, to estimate the risk of treatment for a postoperative UTI, relative to those without use of antibiotics before surgery. Design A historical population-based cohort study. Setting Denmark. Participants Women (age ≥18 years) with a primary surgical procedure for UI from the county of Funen and the Region of Southern Denmark from 1996 throughout 2010. Data on redeemed prescriptions of antibiotics ±365 days from the date of surgery were extracted from a prescription database. Main outcome measures Use of antibiotics for UTI in relation to UI surgery, and the risk of being a postoperative user of antibiotics for UTI among preoperative users. Results A total of 2151 women had a primary surgical procedure for UI; of these 496 (23.1%) were preoperative users of antibiotics for UTI. Among preoperative users, 129 (26%) and 215 (43.3%) also redeemed prescriptions of antibiotics for UTI within 0–60 and 61–365 days after surgery, respectively. Among preoperative non-users, 182 (11.0%) and 235 (14.2%) redeemed prescriptions within 0–60 and 61–365 days after surgery, respectively. Presurgery exposure to antibiotics for UTI was a strong risk factor for postoperative treatment for UTI, both within 0–60 days (adjusted OR, aOR=2.6 (95% CI 2.0 to 3.5)) and within 61–365 days (aOR=4.5 (95% CI 3.5 to 5.7)). Conclusions 1 in 4 women undergoing surgery for UI was treated for UTI before surgery, and half of them had a continuing tendency to UTIs after surgery. Use of antibiotics for UTI before surgery was a strong risk factor for antibiotic use after surgery. In women not using antibiotics for UTI before surgery only a minor proportion initiated use after surgery.

Use of symptom-relieving drugs before and after surgery for urinary incontinence in women: a cohort study

Objective To describe the use of symptom-relieving drugs (antimuscarinic drugs or duloxetine) before and after surgery for urinary incontinence (UI); and for those with use of antimuscarinic drugs or duloxetine before surgery, to estimate the risk of being a postoperative user, relative to those without use before surgery. Design A historical population-based cohort study. Setting Denmark. Participants Women ≥18 years with a first-time surgical procedure for UI from the county of Funen, Denmark between 1 January 1996 and 31 December 2006, extended to the Region of Southern Denmark from 1 January 2007 to the end of 2010. For these women, data on redeemed prescriptions ±365 days of date of surgery were extracted. Main outcome measures Effect of preoperative use of antimuscarinic drugs or duloxetine on the risk of being a postoperative user of these drugs. Results Of 2151 women with a first-time surgical procedure for UI, 358 (16.6%) were preoperative users of antimuscarinic drugs or duloxetine and 1793 were not (83.4%). A total of 110 (30.7%) of the preoperative users also redeemed prescriptions for these drugs within 0–60 days after surgery, and 152 (42.5%) of the preoperative users redeemed prescriptions for these drugs within 61–365 days after surgery. Among preoperative non-users, 25 (1.4%) and 145 (8.1%) redeemed prescriptions within 0–60 and 61–365 days after surgery, respectively. Presurgery exposure to antimuscarinic drugs or duloxetine was a strong risk factor of postoperative drug use, both within 0–60 days (adjusted OR=33.0, 95% CI 20.0 to 54.7) and 61–365 days (OR=7.2, 95% CI 5.4 to 9.6). Conclusions A substantial number of women will continue to be prescribed symptom-relieving drugs after surgery for UI within a year of follow-up. Only a minority of preoperative non-users initiated usage of symptom-relieving drugs after surgery. Compared with other factors included in the regression model, preoperative use of antimuscarinic drugs or duloxetine was the strongest risk factor for postoperative use.