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To evaluate the prevalence and risk factors for adenomyosis, the clinical records of consecutive women undergoing hysterectomy during a 3 year period were retrieved. Data were collected on indication for the intervention, general sociodemographic characteristics of the patients, age at menarche, parity, abortions, and menopausal status at surgery. Adenomyosis was diagnosed in 332 of the 1334 cases (24.9%). The condition was present in 146 of the 627 patients (23.3%) with fibroids and menorrhagia, 68 of the 265 (25.7%) with prolapse, 21 of the 98 (21.4%) with ovarian cysts, 19 of the 100 (19%) with cervical cancer, 31 of the 110 (28.2%) with endometrial cancer, 16 of the 57 (28.1%) with ovarian cancer, and 19 of the 77 (24.7%) with miscellaneous indications. These differences were not statistically significant (chi 2(6) = 11.14). In comparison with nulliparous women, the odds ratio was 1.3 and 1.5 respectively in women with one and > or = two births (chi 2(1) trend = 5.76 P < 0.05). No relationship was found between age at surgery, age at menarche, indications for surgery, menopausal status at intervention, and presence of endometriosis. Our findings do not support the notion that adenomyosis is more frequently related to particular clinical conditions, and suggest that parity may be associated with an increased frequency of adenomyosis.
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PMID:Adenomyosis at hysterectomy: a study on frequency distribution and patient characteristics. 765 58

Short TI inversion recovery magnetic resonance imaging (STIR-MRI) with spin echo (SE) T1-and T2-weighted images of the pelvis was investigated to evaluate its usefulness in detecting and characterizing endometriosis. Thirty-one women suspected of having the disease were studied in detail. MR findings with and without STIR-MRI were correlated with the results of laparotomy (27 women) and laparoscopy (4 women). Surgery revealed endometriosis in 29 women (17 ovarian chocolate cysts, 22 intestinal adhesions, 14 cul-de-sac obliterations and 12 adenomyosis). The other two women did not have endometriosis (uterine prolapse in one and submucosal leiomyoma in one). An ovarian chocolate cyst was diagnosed when a T1-elongated lesion showed shading, loculus or a low intensity rim on SE MR images, and a low intensity rim on STIR-MRI. Only 12 of the 17 chocolate cysts and neither of the two hemorrhagic corpus lutein cysts were correctly diagnosed on SE MR images, whereas 18 of these 19 cysts were correctly diagnosed because of the low intensity rim on STIR-MRI. In the pathological analysis, the rim was found to be a fibrous capsule and there were many macrophages which phagocytized hemosiderin. For the assessment of ovarian chocolate cysts, accuracy improved from 63.2% to 94.7%. As for the adhesion between the intestine and the uterus, specificity improved from 61.9% to 90.5% and accuracy improved from 67.7% to 93.5% when STIR-MRI was used. For the assessment of the cul-de-sac obliteration, accuracy improved from 67.7% to 83.8%, although chi 2 analysis showed no significance. The major factors for the improved accuracy with STIR-MRI are the decrease of the motion artifact owing to the suppression of the fat signal, decreased chemical shift artifact and accurate differentiation of fat from hemorrhagic component. Therefore, STIR-MRI is a useful and reliable procedure and should be used together with SE T1-, T2-weighted images for the assessment of endometriosis.
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PMID:[Detection and characterization with short TI inversion recovery MR imaging]. 780 15

Trends in hospitalizations for selected gynecologic diagnoses per 100,000 women/year associated with hysterectomy were analyzed using the Finnish hospital discharge register data, including each inpatient episode in all Finnish hospitals, from 1971 to 1986. The diagnoses selected were uterine leiomyoma, genital prolapse, the group 'other disorders of the uterus' including endometriosis, and bleeding disorders. These were the most common indications for hysterectomy in Finland from 1987 to 1989, when national data on surgical procedures were included in the hospital discharge register. Trends in the incidence of hospitalizations for malignant neoplasms were also analyzed, although < 10% of hysterectomies are due to gynecological malignancies. Hospitalizations for leiomyoma, endometriosis and bleeding disorders have statistically increased, significantly, among women aged 45 years or more between 1971 and 1986, whereas hospitalizations for prolapse and malignant neoplasms did not show a significant change. Probable incidence of hysterectomy before 1986 was estimated on the basis of the annual incidence of hospitalization for leiomyoma, and hysterectomy for leiomyomas was estimated from the hospital discharge register data of 1988. According to hospital discharge data in 1988, 90% of the hospitalized women with leiomyoma underwent hysterectomy and half of the hysterectomies were performed for leiomyoma. The estimated incidence of hysterectomy increased from 311/100,000 women to approximately 400/100,000 from 1971 to 1986 (slope = 6.5 hysterectomies/100,000/year; 95% C.I. for slope (4.8:8.2)). As the epidemiology of most of the underlying disorders for indications leading to hysterectomy is poorly known, epidemiological studies should consider the determinants of the occurrence of indications independently whether hysterectomy has been performed or not.
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PMID:Five gynecologic diagnoses associated with hysterectomy--trends in incidence of hospitalizations in Finland, 1971-1986. 796 47

Laparoscopic surgery appears now to be not just a series of simple modifications to operative techniques, but more truly a revolution. This is due to three factors: the simultaneous diagnosis of lesions, establishment of the prognosis and actual treatment: greater respect for the anatomy and physiological processes; the shift in the theatre of operations which is now represented by the pelvis itself and not the operating room we were used to. This surgical revolution has achieved a number of indisputable advances, especially where the adnexa are concerned. Tubo-peritoneal infertility, of course, for which Raoul Palmer developed laparoscopy; the approach relies on a thorough knowledge of the tubal condition. Ectopic pregnancy where laparoscopic treatment has become the standard. Ovarian cysts which raise the specific problems of discovering, and even more important, overlooking malignancy. Endometriosis for which surgical treatment has become appropriate again thanks to endoscopy. This revolutionary cycle is not yet complete for subperitoneal surgery is now being addressed. Hysterectomy, so highly symbolic for the gynecologist, is now regularly carried out in this manner. Even cancer surgery may now employ endoscopy, with second-look laparoscopy for ovarian cancer and above all lymphadenectomy techniques which were developed for a large part in France and will no doubt bring about a total change in the strategies for surgical treatment of cancer. Once the technical difficulties have been resolved radical hysterectomy has the potential to become the reference thanks to its precision and radicality. Prolapse too can draw benefit from endoscopic surgery. This is already the case for colpocervical suspension and other factors concerning prolapse are under study. We must not forget that this surgery must not only comply with the standard rules for surgery, but must also benefit from regulated and rigorous training. Collaboration with the engineers and equipment manufacturers is yet another new element with which French medicine is not yet very familiar.
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PMID:[Operative laparoscopy: genuine surgical advance or simple temptation by the feasible?]. 803 2

The results of the first twelve cases of Laparoscopic Assisted Vaginal Hysterectomy, are presented. The indications for hysterectomy were myomatosis, suspicion of adenomyosis and endometriosis. The surgical technique is described in detail in which a combination of bipolar Kleppinger forceps and reusable scissors were employed. There were two intraoperative accidents. One subcutaneous emphysema of the left half of the abdominal wall, thorax, neck, face and upper limb. The second case was a damage to a branch of the left epigastric artery. The average time was 4 hours 31 minutes which includes 9 patients to which another surgical procedure was practiced. There was no significant bleeding in any of the patients. The postoperative complications were 1 hyponatremia that needed the use of an Intensive Care Unit and the other was periumbilical hematoma of 3 cm. of diameter. The patient was discharged on the one to three postoperative day with an average of two days. The average hospital fee was 35% higher than an abdominal hysterectomy. All the surgery were videotaped and later viewed by the patients. It was concluded that the laparoscopic assistance that is offered to the vaginal hysterectomy is particularly advantageous for hysterectomy especially in the cases where absence of genital prolapse, when uni or bilateral Adnexectomy is required, previous past history of abdomino-pelvic surgery, endometriosis and adhesions. This procedure should be included in the armamentarium of the Gynecological Surgeons but only after and appropriate training.
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PMID:[Laparoscopic hysterectomy. Initial experience]. 816 16

The standard technique for total laparoscopic hysterectomy is characterised by two essential points. The first is that all instruments are reusable and the second is that hemostasis is ensured by bipolar coagulation. It is a safe technique with a cost comparable to that of vaginal or abdominal hysterectomies. The routine use of disposable material and automatic disposable staplers for laparoscopic hysterectomies is debatable, as the considerable increase in cost is not accompanied by benefit for the patient or the community. Although laparoscopic hysterectomy is a feasible technique, all hysterectomies should not be performed by this route. If the operation is feasible quickly and under good conditions via the vaginal route, laparoscopic surgery is not indicated. Laparoscopic surgery is only indicated when vaginal surgery is difficult and/or contra-indicated. The elective indications for total laparoscopic hysterectomy are severe adhesions, deep endometriosis and especially a limited vaginal accessibility associated with a narrow vagina and a fixed or non prolapsed uterus. While a average of three quarters of hysterectomies (excluding cases of uterogenital prolapse) are currently performed via a laparotomy, laparoscopic surgery can reduce this rate to approximately 10 to 20 per cent.
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PMID:[Total hysterectomy for benign pathologies. Conventional celiosurgical technique]. 855 73

According to whether uterine artery treatment takes place vaginally or laparoscopically, laparoscopy for hysterectomy can be considered according to two modalities: laparoscopically assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH). The indications for laparoscopy are defined by the limits and/or contraindications of the vaginal route. LAVH is indicated in the following situations: pelvic pain syndrome where diagnosis and treatment can be made at the same time as hysterectomy; minimal endometriosis; past surgical history favouring adhesions formation; necessity to perform an oophorectomy; existence of an ovarian pathology. The elective indications for TLH are the severe pelvic adhesions, deep endometriosis and especially a limited vaginal accessibility associating with a narrow vagina and a fixed or non prolapsed uterus. Laparoscopy thus allows to reduce the number of laparotomies. When on overage three quarters of the hysterectomies (excluding cases of uterogenital prolapse) were up till now performed abdominally, laparoscopy could reduce this rate to approximately 10%.
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PMID:[Complete hysterectomy for benign pathology and laparoscopy: respective indications of laparoscopic preparation and an exclusively laparoscopic approach]. 855 73

Hysterectomy, the most common major nonobstetric operation, is performed in more than 570,000 women in the United States each year. Although the number of hysterectomies has decreased in recent years, many authorities believe that hysterectomy is often unnecessary and unjustified. There is no universally accepted set of criteria regarding the appropriate indications for hysterectomy. The main indications for hysterectomy include the following conditions: uterine leiomyomas, dysfunctional uterine bleeding, endometriosis/adenomyosis, chronic pelvic pain and genital prolapse. Current literature, however, routinely recommends conservative management of most nonmalignant gynecologic conditions, with hysterectomy reserved for refractory cases. Several nonmedical factors, such as patient race, age, geographic location, medical history and background, as well as health care provider characteristics, such as time since completion of training, gender, and affiliation with teaching hospitals, are also associated with hysterectomy rates.
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PMID:Hysterectomy: indications, alternatives and predictors. 933 35

A total of 44 procedures were begun as LAVH with 41 (93%) completed and 3 (7%) attempted but converted to an open approach. Indications were: Leiomyata uteri, 21 (48%); menometrorrhagia, 10 (23%); Uterine prolapse, 6 (14%); endometriosis, 6 (14%); and 1 cervical carcinoma. Four complications occurred. One intraoperative large bowel perforation associated with extensive adhesions occurred and perforation was converted into an abdominal hysterectomy. The perforation was repaired primarily. The 3 remaining complications were delayed vaginal cuff bleeding, one of which required return to the operating room on post-operative day 25 for suturing of the vaginal cuff. The average length of stay was 3 days (range 2-8). The author reviewed the general experience of introducing this new procedure into a community hospital and concluded that LAVH is efficacious and can be safely introduced into a community hospital setting.
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PMID:Laparoscopically Assisted Vaginal Hysterectomy (LAVH) in a Community Hospital: An Initial Experience 907 59

In order to estimate the frequency and risk factors for adenomyosis, the clinical records of 594 women undergoing hysterectomy were retrieved. Data were collected on indications for the intervention, age at surgery, age at menarche, parity, abortions, mode of delivery, abnormal uterine bleeding, dysmenorrhea, and menopausal status at surgery. Adenomyosis was found in 116 of the 594 patients (19.5%). A pathologic condition was present in 63 patients with fibroids (20.5%), 11 with genital prolapse (25.6%), 11 with benign ovarian tumors (17.8%), six with endometrial hyperplasia (13.6%), two with cervical cancer (18.2%), ten with endometrial cancer (16.1%), and 13 with ovarian cancer (21.3%). No relationship was found between adenomyosis and endometriosis. On the contrary, a strong relationship was found between adenomyosis and parity, cesarean section, induced abortions, dysmenorrhea, abnormal uterine bleeding, and late age at menarche. These results show that adenomyosis is a common pathologic finding, significantly related to reproductive and menstrual characteristics of the patients.
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PMID:Adenomyosis at hysterectomy: prevalence and relationship to operative findings and reproductive and menstrual factors. 910 56


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