Robotically Assisted Simple Hysterectomy Health And Social Care Essay

Hysterectomy for non-malignant conditions is the most common major gynecological surgery performed in adult females less than the age of 50 old ages. One in three adult females in the USA will hold a hysterectomy before the age of 60. This works out to about 600,000 hysterectomies performed yearly in the US entirely. ( 1 ) Prior to the debut of laparoscopic-assisted vaginal hysterectomy in the late eightiess, hysterectomies were approached by either a vaginal or an abdominal path via laparotomy scratch. ( 2 ) But since the constitution of the method, its popularity has increased due to the associated benefits when compared with laparotomy for illustration reduced blood loss, shorter infirmary stay, fewer complications etc.

Laparoscopic surgery has revolutionised the construct of minimally invasive surgery for the last 3 decennaries. Robotic-assisted surgery is one of the latest inventions in the field of minimally invasive surgery. It has merely late entered the gynecological surgical sphere, chiefly due to its extra advantages over conventional laparoscopy. ( 3 ) It was approved for usage by the FDA for gynaecologic processs in April 2005. ( 4 )

In the literature to day of the month, robotics has been reported to be used to execute a assortment of different gynecological processs such as simple and extremist hysterectomy, tubal reanastomosis, fix of vesicovaginal fistulous withers, sacrocolpopexy, hysteropexy and myomectomy. For the intent of this reappraisal, literature sing hysterectomy will be discussed.

In a simple hysterectomy, the womb and normally the neck are removed, but the constructions environing are left behind. The vagina is left integral every bit good as the lymph nodes in the pelvic part. The ovaries and fallopian tubings are frequently left every bit good, unless there is some other indicant to besides take them.

With this type of process, the lower urinary piece of land is an country associated with complications. During the hysterectomy, an indwelling Foley catheter is typically used and is kept in situ for 6-12 up to 24 hours or even longer if required. This poses a possible hazard of micro hurt to the urethra or the patient developing dysuria or a bacteuria which is common and therefore has a possible to come on on to a urinary piece of land infection. Other points include patient uncomfortableness and cost. It has been estimated that the hazard of UTI associated with indwelling catheterisation is 5-10 % per twenty-four hours of catheterisation. ( 5 ) and that the commonest cause of UTI in infirmary is urinary catheterisation ( 6 ) In the present paper, the inquiry whether this Foley catheter is truly necessary is investigated the alternate method being to merely utilize a metal “ in out ” catheter as required during the operation and let the patient to invalidate later as normal.

Methods:

Chiefly two databases were used, PubMed and The Cochrane Library in order to seek the literature for relevant articles and clinical tests.

Database

Search Footings

Entire Consequences

Of which were applicable

PubMed

Catheter AND hysterectomy

Catheter AND remotion AND hysterectomy

Early on AND catheter AND remotion AND hysterectomy

818

54

3

8

3

Indwelling AND vesica AND catheter AND hysterectomy

26

4

Cochrane Library

Early on AND catheter AND remotion AND hysterectomy

5

3

Science Direct was searched for the same keywords and yielded the same articles of relevancy.

After filtrating the consequences, 9 articles in entire were applicable to the undertaking. Applicable surveies to this hunt were defined as those associating straight to catheter remotion in instances of hysterectomy.

Consequence:

After an extended reappraisal of the literature, no published surveies were found demoing that the usage of an indwelling catheter, during specifically robotic assisted simple hysterectomy, is either indispensable or non-essential. However there have been surveies turn toing the same inquiry applied to discrepancies of the operation as will be discussed.

Vaginal Hysterectomy:

Survey

Writers

Sample Size

Method

Consequences

Prospective comparing of indwelling vesica catheter drainage vs no catheter after vaginal hysterectomy

( RCT )

Acme, et Al. ( 1994 )

( 7 )

100 adult females undergoing vaginal hysterectomy

Group 1 to hold a Foley catheter for 24 hour

Group 2 to no catheter

Groups indiscriminately assigned

Catheterized group –

2 needed recatheterization, higher incidence of febrility

No catheter group – No recatheterizations.

This one survey, straight associating to merely vaginal hysterectomy, shows that indwelling catheterisation appears to be unneeded after everyday vaginal hysterectomy. However the catheter arrangement does non lend to important station op morbidity. ( 7 ) A failing may be the fact that merely 50 patients were in each group and this may be excessively small to turn out the decision important. None the less, the fact that no patient in the “ no catheter group ” required a recatheterization or experienced a complication ca n’t be ignored.

Abdominal Hysterectomy:

Survey

Writers

Study Type

Sample Size

Method

Consequences

Prospective RCT comparing uninterrupted vesica drainage with catheterisation at abdominal hysterectomy ( TAH )

Dobbs, et Al. ( 1997 )

( 8 )

RCT

100 adult females undergoing entire abdominal hyst.

95 had complete follow-up

Group 1 to hold a foley catheter for 24 hour

Group 2 to no catheter

Groups indiscriminately assigned

Cath. group ( n=48 )

2 needed recatheterization,

No cath. group ( n=47 )

17 needed recatheterization.

Womans undergoing entire abdominal hysterectomy ( TAH ) , who merely had in and out catheterisation at the clip of surgery had a lower rate of bacteuria than those adult females who had indwelling catheters during and post op. ( 8 ) However as the ‘in-out ‘ method ( group 2 ) carried a higher hazard of patient morbidity and besides because indwelling catheterisation for TAH is non associated with any addition in long-run urinary symptoms ( 9 ) , short-run indwelling catheterisation is preferred with TAH despite holding a higher incidence of bacteuria. The strength in this survey lies in the manner it was conducted. It was double blinded until the clip of surgery and is free of prejudice. However it may be said that a failing is in the sample size as merely 95 patients were followed up and the incidence of UTI which the survey was setup to besides look at is unknown since the patients with bacteuria were treated with antibiotics.

Vaginal and Abdominal Hysterectomy

Survey

Writers

Study Type

Sample Size

Method

Consequences

Are indwelling catheters necessary for 24 hours after hysterectomy?

Dunn, et Al. ( 2003 )

( 10 )

RCT

250 adult females in entire

150 – vaginal hyst.

100 – abdominal hyst.

Group 1 to hold a catheter removed instantly post op.

Group 2 to hold catheter removed twenty-four hours 1 station op.

Groups indiscriminately assigned

No difference between both groups in footings of recatheterization, febrility, or UTIs, but significantly fewer studies of terrible station op hurting in the immediate remotion group.

Does early remotion of the Foley catheter after pelvic surgery affect recatheterization, feverish morbidity, diagnostic urinary piece of land infections, and patient comfort

Dunn, et Al. ( 2000 )

( 11 )

RCT

78 adult females in entire

29 for cesarean delivery ( non relevant to this reappraisal )

38 for vaginal hyst.

11 abdominal hyst.

Same as above for each of the single operations.

Consequences non statistically important sing recath. , feverish morbidity and UTI ‘s.

Fewer studies of station op hurting in the immediate remotion group.

These two prospective randomized controlled tests, carried out by the same writers, Dunn, et Al. assessed the usage of the catheter during vaginal and abdominal hysterectomy. To this point these two operations have been talked approximately individually as the surveies mentioned before did non compare them.

The obvious failing to Dunn, et Al. ( 2000 ) was the sample. Possibly for this ground and the inconclusive consequences sing feverish morbidity and UTIs, that this same survey was repeated 3 old ages subsequently. Dunn, et Al. ( 2003 ) ( 10 ) It was dual blind until the clip of surgery utilizing the same method by Summit, et Al. ( 1997 ) .

The findings of the two surveies carried out by Dunn, et Al. yielded the same consequences, the 2003 survey being more statistically important. This strength makes it rather evident that in footings of hurting experienced by the patient, it is significantly reduced by early remotion of the catheter. This may be an betterment for the patients in the early station operative period. The restrictions of the surveies were that the grade of surgical trouble was non assessed. Pain perceptual experience is a subjective step, although attempt was made to standardize it by utilizing the standardised graduated tables, fluctuations of the sensed hurting is likely.

Laparoscopic Assisted Vaginal Hysterectomy ( LAVH ) , Abdominal and Vaginal Hysterectomy.

Survey

Writers

Sample Size

Method

Consequences

Post op urinary results in catheterized and non-catheterized patients undergoing LAVH

Liang, et Al. ( 2009 )

( 12 )

150 adult females undergoing LAVH

Divided into 3 groups of 50.

Group 1 no catheter usage

Group 2 catheter removed day1 station op

Group 3 catheter removed twenty-four hours 2 station op

Groups indiscriminately assigned

Higher incidence of UTI in cath. groups. Grp2 & gt ; grp1

17 from grp 1 required recatheterization compared with 6 from grp 2 and 5 from grp 3

Immediate Foley remotion after laparoscopic and vaginal hyst: Determinants of postoperative keeping

Ghezzi, et Al. ( 2007 )

( 13 )

233 back-to-back adult females undergoing entire laparoscopic hysterectomy ( TLH ) or vaginal hysterectomy ( VH )

2 groups were formed. Numbers unknown as article could non be accessed.

Immediate remotion of catheter followed each of the surgeries.

21 % of patients undergoing TLH or VH failed the first invalidating test and had keeping to some grade.

Prospective, RCT comparing immediate Vs delayed catheter remotion following hyst.

Alessandri, et Al. ( 2006 )

( 14 )

96 adult females undergoing hysterectomy

44 Vaginal Hyst.

37 Abdominal Hyst.

15 LAVH

Patients were indiscriminately assigned to 3 groups for each of the operations.

Grp 1 – immediate cath remotion

Grp 2 – remotion at 6hrs

Grp 3 – remotion at 12 hour

Grp 1 – recatheterization in 6 patients

1 patient developed UTI

Grp 2 and 3 – no recatheterizations but 4 and 5 patients developed UTI severally.

Decreased ambulation clip and shorter infirmary stay in group 1.

Postop. Urinary keeping in gynaecologic patients

Bodker, et Al. ( 2003 )

( 15 )

284 back-to-back adult females undergoing surgical intercession

Relevant:

Abdominal hyst – 124

LAVH – 24

Patients were assessed 6 hour station op whether they required a catheter.

17 abdominal hyst. instances ( 13.9 % ) had keeping versus 2 LAVH instances ( 8.7 % )

The two surveies carried out by Liang, et Al. ( 2009 ) and Alessandri, et Al. ( 2006 ) were carried out in really similar ways. The latter survey besides investigated 2 other operations. The sample size for this survey was non really big. However the same decisions can be gathered from both surveies, that short term catheterisation resulted in lower rate of keeping but higher rate of UTI. These surveies therefore reinforce one another.

In the survey by Bodker, et Al. ( 2003 ) , the keeping rate of 13.9 % after abdominal hysterectomy is similar to that of 11.8 % after gynaecologic laparotomies reported by Schiotz. ( 16 ) There is a tendency, although non statistically important, that the keeping rate is lower after LAVH than abdominal hysterectomy.

Extremist Hysterectomy

Survey

Writers

Study Type

Sample Size

Method

Consequences

The effects of early remotion of indwelling urinary catheter after extremist hysterectomy

Chamberlain, et Al. ( 1991 )

( 17 )

RCT

26 adult females who underwent extremist hyst.

Catheters were removed between the 5th and 9th station op twenty-four hours.

( Median: 6th twenty-four hours )

Control group of 25 patients was besides used. ( Where catheterisation was for 30 yearss )

18 patients were managed successfully and did non hold keeping.

8 patients had keeping but were managed successfully by intermittent ego catheterisation.

Although this survey relates to an operation affecting long term catheterisation, the method by which it was carried out and its decision is of relevancy. On the footing of the informations obtained, early remotion of the urinary catheter ( at 6 yearss compared to 30 yearss ) after extremist hysterectomy is an acceptable option.

Despite the little sample size, the strength of this survey is that the research workers included a control group. It was found that the complications associated with long term catheterisation were avoided by the early remotion and hence the thought is executable.

Discussion:

Coming back to the purpose of this undertaking, that is whether or non Foley catheter usage is required after unsophisticated robotically assisted simple hysterectomy. Assimilating and analysing the bing literature leads one to believe that it may be a executable thought.

Acme, et Al. ( 1994 ) showed that indwelling catheterisation after vaginal hysterectomy is non critical since their informations showed that two patients in the catheterized group required recatheterization and no patient in the no catheter group required recatheterization. This decision is in contrast to that of Dobbs, et Al. ( 1997 ) where it was found that in the ‘in/out ‘ catheterisation group carried a 36 % hazard of keeping versus 4 % after hysterectomy if an indwelling catheter was used. Therefore, differences in postoperative catheter regimen may significantly act upon the hazard of keeping. In this instance the hazard of patient morbidity outweighed the advantage of non utilizing a catheter after abdominal hysterectomy and therefore it is recommended to utilize a catheter. The ground for this may be partially due to the fact that abdominal hysterectomy is a more extended surgical process. The robotic surgery is designed to be more elusive and hence may non come to the same decision.

The keeping rate of 36 % by Dobbs, et Al. is different to that of Bodker, et Al. ( 2003 ) where the rate was 13.7 % after abdominal hysterectomy.

In footings of hurting experienced by the patient, Dunn, et Al. ( 2000 and 2003 ) showed that immediate remotion of the catheter, after vaginal and abdominal hysterectomies, did significantly cut down it. However the feasibleness issue was non addressed in this instance as the consequences were non statistically important.

Laparoscopic hysterectomy is besides non every bit extended as the abdominal method. Liang, et Al. ( 2009 ) investigated the results of the usage and non-use of the catheter. They found a higher incidence of UTI, but a lower incidence of keeping in the catheterized group. The antonym was true for the non-catheterized group. The incidence of keeping following LAVH was 18.7 % . A comparable survey by Gheezi at Al. ( 2007 ) , reported that 21 % of patients undergoing vaginal or laparoscopic hysterectomy had keeping. Works out approximately to be 1 in 5.

Despite the recatheterization rates, Alessandri, et Al. ( 2006 ) found early remotion of the catheter decreased ambulation clip and infirmary stay.

Therefore far, in relation to laparoscopic hysterectomy and vaginal hysterectomy in peculiar, early remotion is a executable thought. Despite the keeping rates, the early remotion is associated with less hurting, earlier ambulation, shorter infirmary stay and lower rate of UTI. With the instances of keeping, scheduled, self intermittent catheterisation or recatheterization seems to allow direction.

Extremist hysterectomy is non investigated in this undertaking as it is a somewhat different more extended operation. None the less the information is interesting to observe. Chamberlain, et Al. ( 1991 ) changed the normal protocol of catheterisation for 30 yearss post op to merely 6 yearss on norm, with no important complications as a consequence.

Since early remotion even in extremist hysterectomy, along with vaginal and besides laparoscopic to some extent is suited, and the fact that the whole thought of minimally invasive surgery is to do the hysterectomy less extended than the bing processs. Based on the literature, it may be probably that the undertaking output a positive consequence.