Laparoscopic-assisted vaginal hysterectomy: a review of usefulness and outcomes.
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Female↗
Biomedical subjects
R L Summitt
Publications and source records attributed to R L Summitt.
Practice management in obstetrics and gynecology residency curriculum.
OBJECTIVE: To establish the current level of instruction in practice management in obstetrics and gynecology residency programs; review recommendations of medical school practice management executives and current and former residents on design of practice management instruction programs; and develop recommendations for future management instruction by residency programs in obstetrics and gynecology. METHODS: A questionnaire was sent to 101 practice plan executives of obstetrics and gynecology departments at medical schools in the United States and Canada. A modified version was sent to 44 current obstetrics and gynecology residents and 72 former residents from the University of Tennessee, Memphis. RESULTS: The response rates were 71% (practice executives), 93% (current residents), and 81% (former residents). There were no formal management programs at 87% of responding institutions, although most respondents (62%) thought there should be mandatory participation in management programs, probably given by organizations outside the university. Potential subjects that received high ratings were current procedural terminology and diagnosis coding, managed care, billing procedures, contractual agreements between medical doctors, patient record management, and practice economics. CONCLUSION: Residency programs should establish formal practice management instruction programs and make participation mandatory. Funding should come from the medical school and university. Instructional help should come from extradepartmental organizations and individuals.
Canada↗
Addressing a state's physician workforce priorities through the funding of graduate medical education: the TennCare model.
TennCare is Tennessee's innovative program that replaces the state's Medicaid program with a health care system based on managed care and designed to cover the vast majority of the state's poor and uninsured. The program provides health care benefits not only to those eligible for Medicaid, but also to the uninsured poor who do not qualify for Medicaid and those who are uninsurable because of existing medical conditions. This article describes the allocation of TennCare graduate medical education funding, which is designed to address the state's physician workforce priorities regarding specialty mix and practice location. Under the new TennCare graduate medical education funding design, funds flow to the state's 4 medical schools and then to the sites of the residents' training. Allocation to the medical schools is based primarily on the number of primary care residents in residency programs under sponsorship of each.
Education, Medical, Graduate↗
Common operations for stress incontinence: selecting the correct operation.
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Algorithms↗
A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates.
OBJECTIVE: To compare intraoperative and postoperative outcomes between laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy among patients who are not eligible for vaginal hysterectomy. METHODS: Study subjects were randomly assigned to undergo laparoscopically assisted vaginal hysterectomy or standard abdominal hysterectomy. Intraoperative and postoperative management was similar for each group. Surgical characteristics, complications, length of hospital stay, charges, and convalescence were analyzed. RESULTS: Sixty-five women at three institutions underwent laparoscopically assisted vaginal hysterectomy (n = 34) or abdominal hysterectomy (n = 31). Three patients in the laparoscopic group required conversion to abdominal hysterectomy. Mean operating time was significantly longer for laparoscopically assisted vaginal hysterectomy (179.8 versus 146.0 minutes). There were no differences in blood loss or incidence of intraoperative complications. There was a higher incidence of wound complications in the abdominal hysterectomy group, but no significant difference in the frequency of postoperative complications. Laparoscopically assisted vaginal hysterectomy required a significantly shorter mean hospital stay (2.1 days) and convalescence (28.0 days) than abdominal hysterectomy (4.1 days and 38.0 days, respectively). There were no significant differences in mean hospital charges between the study groups (laparoscopic $8161, abdominal $6974). CONCLUSION: Except for operating time, there are no differences between laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy regarding intraoperative characteristics among abdominal hysterectomy candidates. Postoperatively, laparoscopically assisted vaginal hysterectomy requires a shorter hospital stay and convalescence. Hospital charges are similar between the procedures. A larger number of cases will help determine the indications for laparoscopically assisted vaginal hysterectomy.
Adult↗
Laparoscopic hysterectomy--is there a benefit?
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Female↗
Peritoneal closure at vaginal hysterectomy: a reassessment.
OBJECTIVE: To evaluate the clinical outcome of patients who underwent vaginal hysterectomy with or without peritoneal closure. METHODS: This study was a randomized trial. Using computer-generated numbers, all patients undergoing vaginal hysterectomy without oophorectomy were randomized to either no peritoneal closure (n = 57) or routine peritoneal closure (n = 49). Patients were followed-up for a minimum of 1 year for development of complications and postoperative dyspareunia. At 4-6 postoperative weeks, the distance between the ovaries and the vaginal cuff was measured by ultrasound. RESULTS: Postoperative complications were similar in both groups. The incidence of deep-thrust dyspareunia at 6 and 12 months was also similar. No statistical differences between the two groups were noted in the ovary to vaginal cuff distances either overall or when patients with dyspareunia were considered separately. CONCLUSION: The data in this study do not support the use of reperitonealization on a routine basis. However, because of a lack of statistical power, larger studies will be required to confirm this theory.
Adult↗
Synthetic hygroscopic cervical dilator use in patients with unsatisfactory colposcopy.
OBJECTIVE: To assess the ability of a synthetic hygroscopic cervical dilator to make an unsatisfactory colposcopic examination satisfactory, thereby avoiding cervical conization. MATERIALS: From April 1991 to March 1993, 30 women with unsatisfactory colposcopic examinations underwent repeat colposcopy after a synthetic hygroscopic cervical dilator had been placed in the endocervical canal for approximately 2 hours. RESULTS: The reasons for initial unsatisfactory colposcopy in the 30 patients were squamocolumnar junction not seen in its entirety (18 patients, 60%), lesion not seen in its entirety (ten, 33%), and neither transformation zone nor lesion seen in their entirety (two, 7%). Complications were encountered in one patient from whom the dilator could not be removed completely. Of 29 patients undergoing repeat colposcopy, 23 (79%) had satisfactory examinations. In 15 of 30 patients, conization was avoided; it was required in six of 30 (20%) women for persistent unsatisfactory colposcopy (including the patient in whom the dilator broke) and in nine of 30 (30%) for other indications. CONCLUSIONS: This experience suggests that a synthetic hygroscopic cervical dilator can be used in patients with an unsatisfactory colposcopy to achieve a satisfactory examination, thus avoiding cervical conization.
Abortifacient Agents↗
GnRH agonist and iron versus placebo and iron in the anemic patient before surgery for leiomyomas: a randomized controlled trial. Leuprolide Acetate Study Group.
OBJECTIVE: To determine the effectiveness of leuprolide acetate depot plus iron compared with iron alone in the preoperative treatment of anemia due to prolonged or excessive bleeding associated with uterine leiomyomas. METHODS: This was a phase III, stratified, randomized, double-blind, placebo-controlled, parallel-group, 12-week multicenter study. Enrolled patients had hemoglobin levels of 10.2 g/dL or less and/or hematocrit values of 30% or less. Patients were entered into one of two strata based on their pre-study hematocrit level: stratum A, hematocrit less than or equal to 28%, and stratum B, hematocrit greater than 28%. Patients within each stratum were randomized to one of three treatment arms: leuprolide acetate depot 7.5 mg, leuprolide acetate depot 3.75 mg, or placebo. All patients received iron orally. Response was defined as a hemoglobin level of 12 g/dL or more and a hematocrit value of 36% or greater. RESULTS: Three hundred nine patients were entered into the study, of whom 265 were evaluated. Using our response criteria, a significantly greater number of patients in both leuprolide acetate groups (combined strata) responded to therapy than did those in the placebo group: 74% in each leuprolide acetate group versus 46% in the placebo group (P < .001). Gonadotropin-releasing hormone agonist-treated patients had a significant reduction in uterine and myoma volume when compared with the placebo group (P < .01). Hot flashes and vaginitis were reported significantly more often (P < .001) in the leuprolide acetate-treated groups than in the placebo group. CONCLUSION: Both dosages of GnRH agonist plus iron were more effective than iron alone in treating the anemia of patients with uterine leiomyomas, in reducing uterine-myoma volume, and in alleviating bleeding and other leiomyoma-related symptoms.
Adult↗
Outpatient vaginal hysterectomy as a new trend in gynecology.
A large number of vaginal hysterectomies are performed on an outpatient basis through ambulatory surgery units (ASU). Recognizing this trend, we researched the possibility of performing vaginal hysterectomies in our ASU and developed an outpatient vaginal hysterectomy protocol. The preoperative and postoperative education we provide to patients is the key to our protocol's success. After conducting patient satisfaction surveys, we reached the conclusion that outpatient vaginal hysterectomies are a successful alternative to inpatient vaginal hysterectomies for many of our patients.
Ambulatory Surgical Procedures↗
Outpatient hysterectomy: determinants of discharge and rehospitalization in 133 patients.
OBJECTIVE: This study examines our continuing experience in performing vaginal hysterectomies and laparoscopy-assisted vaginal hysterectomies with an outpatient protocol. The purpose was to review factors associated with discharge and hospitalization. STUDY DESIGN: Surgical records from all women entering our previously reported outpatient hysterectomy protocol were reviewed. Demographics, surgical indications, intraoperative data, and postoperative data were studied, and their associations with patient discharge and hospitalization were determined. Specific attention was directed to complications. RESULTS: The study group consisted of 133 women. Twelve women (9.0%) were not discharged from the hospital and 5 (3.8%) required readmission. Surgical indications, the type of hysterectomy, and the requirement for pain medication revealed no association with hospitalization. The occurrence of an intraoperative complication (p < 0.000), the need for transfusion (p = 0.043), and postoperative antiemetics (p = 0.013) were statistically associated with hospitalization. In addition, low hematocrit values and elevated temperatures on the first and second postoperative days were associated with hospitalization. CONCLUSION: Long-term experience with outpatient hysterectomy reveals a hospitalization rate of 12.8%. Complications, blood loss, elevated temperatures, and postoperative nausea are the major determinants of patient discharge and hospitalization. Readmission rates continue to remain low.
Adolescent↗
Prospective comparison of indwelling bladder catheter drainage versus no catheter after vaginal hysterectomy.
OBJECTIVE: This study compares the postoperative outcomes of patients in whom indwelling bladder catheterization or no catheter was used after vaginal hysterectomy. STUDY DESIGN: One hundred women undergoing inpatient vaginal hysterectomy were randomly assigned to have an indwelling Foley catheter for 24 hours or no catheter after the procedure. Data regarding postoperative morbidity were recorded, and a clean voided urine specimen for urinalysis and culture was obtained 48 hours and 2 weeks after surgery. RESULTS: The study groups were similar with respect to demographics and surgical indications. Two patients in the catheterized group required recatheterization after the catheters were removed. None of the subjects in the no-catheter group required a catheter. There was a significantly higher incidence of fever in the catheter group. No differences were found in the incidence of positive urine cultures between the study groups at 48 hours (8 vs 14, p = 0.227) and 2 weeks (6 vs 1, p = 0.111), respectively. CONCLUSION: Indwelling catheterization appears unnecessary after routine vaginal hysterectomy. However, catheter placement for 24 hours does not contribute significantly to postoperative morbidity.
Adult↗
Serum bupivacaine levels during laparoscopic sterilization using local anesthesia.
STUDY OBJECTIVE: To determine the serum levels of bupivacaine during laparoscopic sterilization when bupivacaine 0.5% without epinephrine is used as the sole local anesthetic agent. DESIGN: Case series. SETTING: Regional medical center and primary teaching hospital of Ob/Gyn Department of the University of Tennessee, Memphis. PATIENTS; Thirty women undergoing laparoscopic sterilization with bupivacaine for local anesthesia. INTERVENTIONS: Venous serum bupivacaine levels were measured, with samples drawn at 45, 60, 90, and 120 minutes after injection in 25 patients. Five additional patients had sampling at 15 and 30 minutes as well as at the above times. MEASUREMENTS AND MAIN RESULTS: The highest concentration of bupivacaine was detected at 15 minutes. The mean concentrations at 15, 30, 45, 60, and 120 minutes were 0.86, 0.74, 0.31, 0.27, 0.23, and 0.22 microg/ml, respectively. This is well below the level of serious toxicity. Only four patients received 2.5 mg/kg or greater of bupivacaine. In these patients, mean serum levels were 1.1, 1.0, 0.28, 0.43, 0.9, and 0.29 microg/ml, respectively. CONCLUSION: Serum bupivacaine levels during sterilization using bupivacaine 0.5% without epinephrine for local anesthesia are well below the threshold for serious toxicity.
Anesthesia, Local↗
The effect of nitrous oxide and carbon dioxide pneumoperitoneum on operative and postoperative pain during laparoscopic sterilization under local anesthesia.
STUDY OBJECTIVE: To compare carbon dioxide and nitrous oxide pneumoperitoneum with respect to intraoperative and postoperative pain during laparoscopic sterilization under local anesthesia. DESIGN: Randomized, double-blind study of pain during surgery and at 15 minutes, 1 hour, and 24 hours postoperatively. SETTING: Regional Medical Center, Memphis, Tennessee. PATIENTS: Women scheduled for laparoscopic sterilization under local anesthesia. Interventions. Forty-nine patients were randomized to carbon dioxide and 56 to nitrous oxide pneumoperitoneum. MEASUREMENTS AND MAIN RESULTS: Pain was assessed using a modified McGill pain questionnaire. Intraoperative pain was measured by the amount of supplemental narcotic required. Analgesic use in the recovery room and during the first 24 hours postoperatively was compared. Demographics for both groups were similar. The groups had no statistical differences in pain during surgery or at any of the postoperative time periods. Recovery room analgesia requirement was similar, but the nitrous oxide group used fewer pain tables (0.98 vs 0.42 tablets) in the first 24 hours. CONCLUSIONS: There is no difference in intraoperative and postoperative pain between nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic sterilization when used in conjunction with a protocol such as ours.
Administration, Oral↗
Evaluation of pressure transmission ratios in women with genuine stress incontinence and low urethral pressure: a comparative study.
OBJECTIVE: To determine whether women with genuine stress incontinence and low urethral closure pressure (20 cm H2O or lower) had more severely impaired pressure transmission to the urethra than women with stress incontinence and normal urethral pressures. METHODS: Seventy-six women who underwent multichannel urodynamic testing were included for comparative analysis. They were classified into the following groups: genuine stress incontinence with low urethral pressure (N = 20), genuine stress incontinence without low urethral pressure (N = 32), and continent controls (N = 24). Urodynamic indices and pressure transmission ratios were calculated from static and stress urethral pressure profiles, respectively. Multiple demographic cofactors, urethral mobility, and previous surgeries were correlated for associations with urodynamic results. RESULTS: Women with stress incontinence and low urethral pressure were significantly older (57.6 years, P < .0071). There were no differences with regard to urethral mobility and previous surgeries. Mean maximum urethral closure pressure and the distance from the proximal margin of the urethra to the point of maximum urethral closure pressure were statistically less in women with low urethral pressure. There were no differences in pressure transmission ratios between any of the study groups. CONCLUSION: Because there are no differences in pressure transmission ratios between women with genuine stress incontinence with and without low urethral closure pressure, the higher risk for surgical failure with low urethral pressure appears to result from another pathophysiologic process.
Female↗
Nephrogenic adenoma in a urethral diverticulum. A case report.
A nephrogenic adenoma was identified histologically in the excised specimen of a urethral diverticulum. Urethral diverticulum is a relatively common disorder of the female lower urinary tract, and nephrogenic adenoma is an extremely rare finding: this is the 13th reported case of this association. Of clinical importance is the close histopathologic resemblance of nephrogenic adenoma to clear cell adenocarcinoma. Nephrogenic adenoma is a benign metaplastic change of the urothelium in response to repair.
Adenoma↗
A model for resident surgical training in laparoscopic sterilization.
OBJECTIVE: To measure the effects of a specific instructional program designed to teach residents laparoscopic sterilization. METHODS: The teaching module consisted of a 40-minute videotape and monograph, which each resident studied 1-3 days before beginning a 4-5-week rotation on which he or she performed laparoscopic sterilization procedures. The change in knowledge was measured by comparing pre- and post-test assessments. Twenty-three PGY-2 gynecology residents were administered the peer-reviewed and validated pre-test, which consisted of 31 multiple-choice questions covering the following aspects of laparoscopic sterilization: 1) indications and complications, 2) general aspects of sterilization, 3) sterilization methods, and 4) technical aspects of occlusive device application. A post-test, which consisted of the identical 31 items with the question order changed, was administered after the teaching module was completed. RESULTS: The mean number of correct answers on the post-test (27.2 +/- 2.3, range 22-31) was significantly higher (P < .05) than the mean number of correct answers on the pre-test (17.9 +/- 3.4, range 13-24). There was no difference in residence scores if the module was completed early or late in the academic year or during the first or second year that the program was in effect. CONCLUSION: This study demonstrates that knowledge of a specific surgical technique can be measured and that structured learning packages can be effective. Efforts to teach residents a specific curriculum can have a significant effect on their fund of knowledge. Other specially designed programs may be applicable to procedures commonly performed by gynecologic residents.
Curriculum↗
Chromopertubation at laparoscopic tubal occlusion.
OBJECTIVE: To evaluate the role of chromopertubation following laparoscopic sterilization in terms of occlusive device displacement, infectious complications, and sterilization failures. METHODS: Five hundred consecutive women scheduled for laparoscopic sterilization were randomized to rings, electrocoagulation, or clips for tubal occlusion. Subjects were further randomized to chromopertubation or no chromopertubation. At chromopertubation, any occlusive device displacement or dye spillage was noted. Patients were followed postoperatively for sterilization failure or infectious complications. Statistical analysis used the chi 2 test. RESULTS: At chromopertubation, no device dislodgment, change in position, or dye spillage from the occlusion site was noted. Dye spillage from the end of the fallopian tube occurred in five patients, and immediate repeat tubal occlusion was performed. Six true sterilization failures occurred during the follow-up period. Despite elimination of five apparent failures in the chromopertubation group, there was no significant difference between the no-chromopertubation and chromopertubation groups with regard to failure rate. There were also no significant differences in postoperative wound infections or development of pelvic inflammatory disease. CONCLUSION: Chromopertubation at sterilization is associated with minimal complications but has limited value in eliminating sterilization failures.
Fallopian Tube Patency Tests↗