Abstracts

INTRODUCTION

Gynecologic Surgery is a branch of General Surgery that treats the female genital tract and surgical diseases of women, considering the breasts and pelvis. As for the pelvic area, the main benign diseases requiring surgical procedures relate to the uterus and its appendages and correction of urinary incontinence. However, specific features of certain populations bring peculiarities to the indications and results obtained^1.2.

The city of Boa Vista, capital of Roraima, lies on the northern reaches of the Brazilian Amazon, has a population of 314,900 inhabitants (63% of the state population), of which around 70,000 women aged between 20 and 50 years. Most of this contingent inhabits the urban area, 2.5% living in rural areas. The per capita monthly income is R $786.00, comparatively lower than in São Paulo (R$ 1,516.00), one of the main capitals of the country. As an example of local health care characteristics, according to IBGE data, the city has only four inpatient units in emergency obstetric and four mammography centers³3. Brasil. Ministério da Saúde. IBGE - Instituto Brasileiro de Geografia e Estatística [Internet]. Estatísticas da saúde. Assistência médico-sanitária; 2009. [acessado em: 2014 outubro 8]. Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/ams/2009/ams2009.pdf.
http://www.ibge.gov.br/home/estatistica/... .

Thus, knowing the results in Gynecological Surgery of this social model opens up the possibility of designing unique regional parameters. In general, the most common surgical procedures for gynecological benign diseases in women are hysterectomy and operations for urinary incontinence and pelvic organ prolapse correction¹1. Merighi MAB, Oliveira DM, Jesus MCP, Hoga LAK, Pedroso AGO. Experiências e expectativas de mulheres submetidas à histerectomia. Texto contexto - enferm. 2012;21(3):608-15.^,22. Costa AAR, Amorim MMR, Cursino T. Histerectomia vaginal versus histerectomia abdominal em mulheres sem prolapso genital, em maternidade-escola do Recife: ensaio clínico randomizado. Rev Bras Ginecol Obstet. 2003;25(3):169-76.^,44. Chen B, Ren DP, Li JX, Li CD. Comparison of vaginal and abdominal hysterectomy: A prospective non-randomized trial. Pak J Med Sci. 2014;30(4):875-9.. Hysterectomy is the second most common surgical procedure performed in women of reproductive age, only surpassed by cesarean section; about 20-30% of women will undergo this operation until the sixth decade of life. The way to perform hysterectomy include vaginal, abdominal and laparoscopic routes. In many countries, the mainly used is the abdominal (70-90%), with only 10-30% vaginal and less than 5% laparoscopic¹1. Merighi MAB, Oliveira DM, Jesus MCP, Hoga LAK, Pedroso AGO. Experiências e expectativas de mulheres submetidas à histerectomia. Texto contexto - enferm. 2012;21(3):608-15.^,22. Costa AAR, Amorim MMR, Cursino T. Histerectomia vaginal versus histerectomia abdominal em mulheres sem prolapso genital, em maternidade-escola do Recife: ensaio clínico randomizado. Rev Bras Ginecol Obstet. 2003;25(3):169-76.^,44. Chen B, Ren DP, Li JX, Li CD. Comparison of vaginal and abdominal hysterectomy: A prospective non-randomized trial. Pak J Med Sci. 2014;30(4):875-9..

Urinary incontinence (UI), on its turn, represents about 10% of gynecological complaints⁵5. Tanuri ALS, Feldner Jr PC, Bella ZIKJ, Castro RA, Sartori MGF, Girão MJBC. "Sling" retropúbico e transobturário no tratamento da incontinência urinária de esforço. Rev Assoc Med Bras. 2010;56(3):348-54.

6. Feuser MR, Luz CM, Virtuoso JF, Luz SCT, Longo EK, Espíndola DS. Comportamento da continência urinária após tratamento cirúrgico com faixa sintética (sling): um estudo de sete casos. ACM arq catarin med. 2011;40(2):41-6.

7. Silveira ABFN, Fogiatto D, Kulak Júnior J, Busato D, Francisco JAFC. Sling transobturário: resultados de um centro de uroginecologia em Curitiba no ano de 2004. Rev Col Bras Cir. 2007;34(2):123-6.

8. Sartori JP, Martins JAM, Castro RA, Sartori MGF, Girão MJBC. Sling de aponeurose e com faixa sintética sem tensão para o tratamento cirúrgico da incontinência urinária de esforço feminina. Rev Bras Ginecol Obstet. 2008;30(3):127-34.

9. Feldner Jr PC, Bezerra LRPS, Girão MJBC, Castro RA, Sartori MGF, Baracat EC, et al. Valor da queixa clínica e exame físico no diagnóstico da incontinência urinária. Rev Bras Ginecol Obstet. 2002;24(2):87-91.^-1010. Feldner Jr PC, Sartori MGF, Lima GR, Baracat EC, Girão MJBC. Diagnóstico clínico e subsidiário da incontinência urinária. Rev Bras Ginecol Obstet. 2006;28(1):54-62.. The operative techniques of suburethral sling for correction of UI can use a wide variety of autologous and synthetic materials and consist of the use of a strip positioned inferiorly to the urethra or bladder neck without tension. Their cure rates range between 61% and 93%¹¹11. Rovner ES, Ginsberg DA, Raz S. The UCLA surgical approach to sphincteric incontinence in women. World J Urol. 1997;15(5):280-94.^,1212. Martins JAM, Castro RA, Girão MJBC, Sartori MGF, Baracat EC, Lima GR. Correção da incontinência urinária de esforço com sling: resultados iniciais. Rev Bras Ginecol Obstet. 2000;22(5):301-5.. The use of synthetic meshes in sling procedures reduces the operation time and eliminates the potential morbidity at the graft site extraction⁵5. Tanuri ALS, Feldner Jr PC, Bella ZIKJ, Castro RA, Sartori MGF, Girão MJBC. "Sling" retropúbico e transobturário no tratamento da incontinência urinária de esforço. Rev Assoc Med Bras. 2010;56(3):348-54.^,1313. Cândido EB, Triginelli SA, Silva Filho AL, Noviello MB, Santos Filho AS, Silva LB. Utilização de pericárdio bovino no sling pubovaginal para o tratamento da incontinência urinária de esforço. Rev Bras Ginecol Obstet. 2003;25(7):525-8..

The aim of this study was to evaluate the clinical and epidemiological profile of patients undergoing gynecological surgeries due to benign disease in a reference center of Roraima.

METHODS

We conducted a cross-sectional, retrospective, descriptive study through the analysis of medical records of 518 patients who underwent surgical treatment between January and June 2012 at the Women's Health Reference Center (CRSM) of the Hospital Materno-Infantil Nossa Senhora de Nazaré (HMINSN), a public tertiary hospital in Boa Vista, Roraima, on the northern reaches of the Brazilian Amazon.

We selected the three major gynecological operations, totaling 436 patients. Of these, we excluded 236 tubal sterilizations (45.5%) and other 25 cases (12.5%) due to lack of access the medical records.

The epidemiological variables analyzed were type and number of deliveries, pre and postoperative diagnosis and postoperative complications, through measures of central tendency (median, mode and relative frequency). The study was approved by the Ethics in Research Committee of the Federal University of Roraima (UFRR), Protocol 609 239.

The patients underwent transvaginal ultrasound and Pap smear for preoperative evaluation. In cases of hysterectomy, the uterus was sent for histopathological evaluation after the procedure.

The results obtained in the study were divided into categorical and continuous variables for analysis. Categorical variables were analyzed descriptively, by calculating absolute and relative frequencies. Continuous variables are expressed as means, medians, standard deviations, absolute and relative frequencies. To compare proportions we used the chi-square test and, where appropriate, Yates' correction. The level of significance was set at p <0.05 for all tests.

RESULTS

We performed 518 operations. The most prevalent gynecological procedures in the Service were hysterectomy, colpoperineoplasty, vaginal sling surgery and cistopexy with or without perineoplasty, corresponding to 175 cases (Table 1). The average age of patients was 47.6 years, ranging from 24 to 84, with a predominance of the range between 40 and 49 years (45.7, CI: 38.18-53.40). The predominant level of education was completed junior high school, in 36.6% of cases, 27.4% had completed high school, and 5.7% of patients attended higher education (Table 2). The patients were mainly from the State capital (77%), married or in a stable relationship (47.4%) and housewives (26.3%).

Patients were multiparous (three or more previous deliveries) in 86.6% of cases, 50.2% with only vaginal deliveries and 21% had a history of at least one previous cesarean delivery. The Pap smear showed high-grade cervical intraepithelial neoplasia in 1.7% of patients.

Preoperative diagnoses were uterine myoma in 46.3%, urinary incontinence in 27.4%, and genital dystopia in 17.7% as indications for hysterectomy, vaginal Sling and colpoperineorrhaphy, respectively. All patients were followed for a minimum of six months postoperatively. Most patients had no postoperative complication (89.1%). The complications were wound infection, urinary tract infection, urinary retention, vaginal mesh extrusion, vaginal opening granuloma, thigh hematoma/pain, bladder injury and post- spinal anesthesia headache (Table 3).

There was a correlation between postoperative histopathology with preoperative diagnosis of uterine leiomyoma, with statistical significance (p = 0.004 Yates X²). There was no significant relationship between endometrial hyperplasia and endometrial thickening in the preoperative ultrasound. The main histopathological findings were 36 cases of leiomyoma, four cases of endometrial hyperplasia without atypia and 24 cases of adenomyosis.

DISCUSSION

The major benign gynecological conditions with surgical indication are uterine myoma and urinary incontinence. While in specialized centers they are treated today with minimally invasive techniques, in centers distant from large capitals the conventional surgical treatments dominate²2. Costa AAR, Amorim MMR, Cursino T. Histerectomia vaginal versus histerectomia abdominal em mulheres sem prolapso genital, em maternidade-escola do Recife: ensaio clínico randomizado. Rev Bras Ginecol Obstet. 2003;25(3):169-76.^,55. Tanuri ALS, Feldner Jr PC, Bella ZIKJ, Castro RA, Sartori MGF, Girão MJBC. "Sling" retropúbico e transobturário no tratamento da incontinência urinária de esforço. Rev Assoc Med Bras. 2010;56(3):348-54..

Interestingly, the average age of the patients submitted to surgery was 47.6 years, consistent with the literature¹⁴14. Carvalho Júnior AM, Carretette FB, Muller V, Vaz FP. Estudo comparativo entre sling pubovaginal de parede vaginal e sling de fáscia do reto abdominal no tratamento da incontinência urinária de esforço. Rev Col Bras Cir. 2003;28(3):203-7.

15. Frare JC, Souza FT, Silva JR. Perfil de mulheres com incontinência urinária submetidas a procedimento cirúrgico em um hospital de ensino do sul do país. Semina cienc biol saude. 2011;32(2):185-98.^-1616. Santos CRS, Santos VLCG. Prevalência da incontinência urinária em amostra randomizada da população urbana de Pouso Alegre, Minas Gerais, Brasil. Rev Latino-Am Enfermagem. 2010;18(5):903-10..

As for the origin of the patients, in Brazilian studies 81.5% to 92.6% of patients were from the town itself and 7.37% to 18.43% lived in the countryside¹⁴14. Carvalho Júnior AM, Carretette FB, Muller V, Vaz FP. Estudo comparativo entre sling pubovaginal de parede vaginal e sling de fáscia do reto abdominal no tratamento da incontinência urinária de esforço. Rev Col Bras Cir. 2003;28(3):203-7.

15. Frare JC, Souza FT, Silva JR. Perfil de mulheres com incontinência urinária submetidas a procedimento cirúrgico em um hospital de ensino do sul do país. Semina cienc biol saude. 2011;32(2):185-98.^-1616. Santos CRS, Santos VLCG. Prevalência da incontinência urinária em amostra randomizada da população urbana de Pouso Alegre, Minas Gerais, Brasil. Rev Latino-Am Enfermagem. 2010;18(5):903-10.. In our study, most patients had urban origin (77%). It is believed that the prevalence of patients coming from the urban area served by the service is due to patients from the countryside and surrounding towns lacking access to information and public health services. In an IBGE survey in 2009 in the North of the country, only 1.8 hospital beds were available for every 1,000 inhabitants, below the standard recommended by the Ministry of Health, and, in Roraima, these beds are available for the SUS, the Brazilian NHS, in only four health establishments³3. Brasil. Ministério da Saúde. IBGE - Instituto Brasileiro de Geografia e Estatística [Internet]. Estatísticas da saúde. Assistência médico-sanitária; 2009. [acessado em: 2014 outubro 8]. Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/ams/2009/ams2009.pdf.
http://www.ibge.gov.br/home/estatistica/... .

With regard to deliveries, 86.6% of women were multiparous, concordant with world literature, but higher than other Brazilian samples, such as Primo et al., who found 37.5% multiparous¹⁷17. Primo CC, Plaster FA, Bravin MF, Leite FMC, Lima EFA. Perfil epidemiológico de mulheres submetidas à cirurgia na Unidade de Ginecologia de um hospital universitário. REME rev min enferm. 2012;16(4):494-501.. The predominant level of education was complete junior high in 36.6%¹¹11. Rovner ES, Ginsberg DA, Raz S. The UCLA surgical approach to sphincteric incontinence in women. World J Urol. 1997;15(5):280-94.^,1515. Frare JC, Souza FT, Silva JR. Perfil de mulheres com incontinência urinária submetidas a procedimento cirúrgico em um hospital de ensino do sul do país. Semina cienc biol saude. 2011;32(2):185-98.^,1616. Santos CRS, Santos VLCG. Prevalência da incontinência urinária em amostra randomizada da população urbana de Pouso Alegre, Minas Gerais, Brasil. Rev Latino-Am Enfermagem. 2010;18(5):903-10.. Multiparity is a known risk factor for genital dystopias and urinary incontinence. Studies show that every birth increases by 1.2% the risk for dystopias and that among women who had two or more births, the number of hospitalizations for genital prolapse repair increases by up to eight times when compared to nulliparous women¹⁸18. Lima MIM, Lodi CTC, Lucena AA, Guimarães MVMB, Meira HRC, Lima LM, Lima SA. Prolapso genital. Revisão. FEMINA. 2012;40(2):69-77..

The most common complication was wound infection, present in 2.2% of patients, consistent with the findings in the literature. Regarding the extrusion of synthetic mesh through the vagina, we found a frequency of 9.5% among patients undergoing sling surgery. In the literature mesh extrusion rate is 0-14%, and in other Brazilian studies, 4%⁷7. Silveira ABFN, Fogiatto D, Kulak Júnior J, Busato D, Francisco JAFC. Sling transobturário: resultados de um centro de uroginecologia em Curitiba no ano de 2004. Rev Col Bras Cir. 2007;34(2):123-6..

It should be noted that this study is a pioneering survey on the characteristics of gynecologic surgeries performed in the far north of the country. The limitation of the results lie in its retrospective nature, based on information collected from medical records and dependent on correct completion. From this data, the first time in our country, we wanted to know the characteristics of these patients, which could help promote management strategies adapted to the local population, as well as the establishment of possible preventive measures directed to these women.

The sample shows that women undergoing gynecological operations due to benign diseases in the Centro de Referência de Saúde da Mulher (CRSM) do Hospital Materno-Infantil Nosssa Senhora de Nazaré (HMINSN) between January and June 2012 had an average age of 47, most had completed junior high, came from the State capital, were in a stable relationship, were predominantly housewives, multiparous and showed low operative complication rates.

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