Hysterectomy is performed for a wide range of benign and malignant conditions, such as fibroids, menorrhagia and pelvic pain, and gynaecological malignancies. One in four women has a chance of undergoing hysterectomy in her lifetime. Conventionally abdominal hysterectomy is done through the open approach. However, many patients assume that the modern laparoscopic hysterectomy is superior to the standard approach. Laparoscopic surgical centres are mushrooming in major cities. This article presents ethical considerations involved in the decision-making process of choosing from the surgical options available.
Vaginal hysterectomy for the large uterus is seldom performed in Malaysia. The traditional operation is abdominal hysterectomy. This is a personal series of vaginal hysterectomies for enlarged uterus of more than 12 weeks size (>280g) carried out in a private hospital between 1/1/97 to 30/9/2000. A total of 40 cases were done with the weights of the uterus ranging from 290g to 790g. The mean weight of the uterus was 434g. The average operating time was 92.1 min. The complications were minimal with 2 cases of blood transfusion for intra-operative hemorrhage, 1 case of fever and 1 case of bladder perforation. This series demonstrates feasibility and safety of the operation. The excellent recovery due to the absence of an abdominal scar should be a strong incentive for specialists to learn the skill.
This is a retrospective observational study of outcome of 11 cases of vaginal hysterectomy for undescended and enlarged uterus carried in University Hospital, Kuala Lumpur. The cases included relative contraindications such as 14 weeks size fibroids, severe obesity, previous Caesarean section and nulliparity. All the eight patients agreeable for prophylactic bilateral salpingoophorectomy had their ovaries removed. Operative time ranged from 1 hr 20 min to 2 hr 15 min. All patients were sent home within 48 hours of the operation. The excellent outcome of our initial experience highlights the known advantages of vaginal hysterectomy for undescended and enlarged uterus.
The postoperative effects on Asian women after hysterectomy have not been fully explored. This study was undertaken to investigate the physical, psychological and sexual functioning effects in multi-ethnic Malaysian women who have undergone hysterectomy.
Matched MeSH terms: Hysterectomy/adverse effects; Hysterectomy/psychology*; Hysterectomy/statistics & numerical data
A young adult patient with 46XX congenital adrenal hyperplasia (CAH) presented with recurrent painful haematuria. CAH was diagnosed at birth following ambiguous genitalia. Hormonal treatment was started, female gender was assigned and feminising genitoplasty was planned, however the patient was lost to follow-up. Gender dysphoria started to occur during childhood which prompted the family to raise the patient as a boy. He eventually identified himself as a male. Examination revealed a male phenotype with severely virilised genitalia. Imaging studies confirmed the presence of uterus with low confluent urogenital sinus. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed, and the troublesome symptoms were cured.
A prospective cross-sectional study involving 14 government hospitals was undertaken for a period of 6 months in Malaysia to study the patterns of hysterectomy for gynaecological indications. A total of 707 patients were enrolled in the study consisting of 612 abdominal hysterectomies and 95 vaginal hysterectomies. Fibroids (47.6%) and uterovaginal prolapse (13.4%) formed the main indications for surgery. The initial preoperative diagnosis was accurate in 82.8% of cases. A different pathology from that initially suspected was noted in 118 cases. The overall complication rate was 7.9% but vaginal hysterectomies carried a statistically higher complication rate compared to abdominal hysterectomies. Urinary tract infection was significant in vaginal hysterectomies. Blood transfusion was required in 25.0% of abdominal and 6.3% of vaginal hysterectomies. There were no laparoscopic hysterectomies or mortality in this series.
Comment in: Soh EB, Ng KB. A survey of hysterectomy patterns in Malaysia. Med J Malaysia. 1999 Mar;54(1):152-4; Teoh TG. Hysterectomies in Malaysia: why are we left behind? Med J Malaysia. 1999 Mar;54(1):151-2
Eight patients underwent major gynaecological operations. Their post-operative analgesia was provided by epidural buprenorphine 0.15 mg and bupivacaine 0.5%. The efficacy and side-effects of this combination were assessed. All patients had satisfactory analgesia ranging in duration from 10 hours to greater than 36 hours after a single dose injection. No significant side-effect was noted.
A case is described of profuse uterine bleeding with a dislodged Multiload Cu 250 intrauterine device (IUD). Multiple blood transfusions were necessary, and ultimately, an emergency hysterectomy was performed.
Magnetic Resonance-guided focused Ultrasound Surgery (MRgFUS) is gaining popularity as an alternative to medical and surgical interventions in the management of symptomatic uterine fibroids. Studies have shown that it is an effective non-invasive treatment with minimal associated risks as compared to myomectomy and hysterectomy. MRgFUS can be offered to a majority of patients suffering from symptomatic uterine fibroids. It has been suggested that the use of broader inclusion criteria as well as the mitigation techniques makes it possible to offer MRgFUS to a much larger subset of patients than previously believed. This paper will describe how MRgFUS treatment for uterine fibroids is performed at the University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
Cornual pregnancy happens when implantation occurs in the cavity of a rudimentary horn of the uterus, which may or may not be communicating with the uterine cavity. The diagnosis of cornual pregnancy remains challenging, and rupture of a cornual pregnancy usually causes massive bleeding. Early diagnosis and treatment, therefore, are very crucial and key to prevent mortality. Historically, the management of cornual pregnancies included wedge resection through open surgery or even hysterectomy. In this case report, we would like to highlight a case of late second trimester cornual pregnancy, at 19-week and 3-day gestation, which was managed laparoscopically.
Endometrial stromal sarcoma is a rare tumour of the uterus. We reported a case of a young lady with endometrial stromal sarcoma. She became pregnant while having the disease and delivered a healthy baby, her sixth, without any complication. A total abdominal hysterectomy with bilateral oopherectomy was performed subsequently. She refused any added treatment after the operation. To date, she is free of any recurrence.
Vulvo-vaginal haematomas are not an uncommon obstetric complication. Despite advances in obstetric care, practice and technique, vulvo-vaginal haematomas do occur especially in complicated vaginal deliveries. Various management options are available for vulvo-vaginal haematomas. We describe three cases of vulvo-vaginal haematomas with different severity and presentations which were managed in different manners i.e. local haemostasis control, laparotomy with hysterectomy, and transarterial embolisation. The choice of treatment options would mainly depend on the clinical presentations, availability of expertise as well as facilities. Early identification is crucial.
A rare case of hydatidiform mole occurring 7 consecutive times in a Chinese woman is presented. She was first seen in 1979 at the age of 23 years, with a molar pregnancy and subsequently had 6 consecutive moles, the last being in July, 1986; at this visit the patient and her husband were very depressed, and convinced that a normal pregnancy was unlikely and requested a hysterectomy. They were warned earlier several times, of the possible long-term consequences of a recurrent mole and that their chance of having a normal baby was very remote. A total hysterectomy was performed at her last presentation as the patient requested one, instead of dilatation and curettage for a persistently high HCG and bulky uterus following suction evacuation. Histology revealed an invasive mole. The beta HCG level was less than 4IU/l by the end of September, 1986 and she is still being followed-up.
Villoglandular papillary adenocarcinoma was first described by Young and Scully in 1989 as a distinct entity with the histological features of exophytic growth proliferation, villous and papillary architecture and mild to moderate nuclear atypia. We report one case of villoglandular papillary adenocarcinoma (VGPA) of the uterine cervix with lymph node metastasis and reviewed the clinicopathological features of six other cases reported in the literature. Our patient is the seventh similar reported cases. They ranged in age from 29 to 54 (mean, 41) years. Five had lymphovascular invasion. All except our patient were treated with radical hysterectomy and radiotherapy. She was followed-up for 7 months and unfortunately died due to chest infection.