Publications by authors named "Marion Ek"

11 Publications

  • Page 1 of 1

Effects of Obesity on Peri- and Postoperative Outcomes in Patients Undergoing Robotic versus Conventional Hysterectomy.

J Minim Invasive Gynecol 2021 02 6;28(2):228-236. Epub 2020 May 6.

Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet (Drs. Brunes, Söderberg, and Ek), Stockholm, Sweden; Division of Obstetrics and Gynecology, Södersjukhuset (Drs. Brunes, Söderberg, and Ek), Stockholm, Sweden.

Study Objective: To assess if women with obesity have increased complication rates compared with women with normal weight undergoing hysterectomy for benign reasons and if the mode of hysterectomy affects the outcomes.

Design: Cohort study.

Setting: Prospectively collected data from 3 Swedish population-based registers.

Patients: Women undergoing a total hysterectomy for benign indications in Sweden between January 1, 2015, and December 31, 2017. The patients were grouped according to the World Health Organization's classification of obesity.

Interventions: Intraoperative and postoperative data were retrieved from the surgical register up to 1 year after the hysterectomy. Different modes of hysterectomy in patients with obesity were compared, such as open abdominal hysterectomy (AH), traditional laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and robot-assisted laparoscopic hysterectomy (RTLH).

Measurements And Main Results: Out of 12,386 women who had a total hysterectomy during the study period, we identified 2787 women with normal weight and 1535 women with obesity (body mass index ≥30). One year after the hysterectomy, the frequency of complications was higher in women with obesity than in women with normal weight (adjusted odds ratio [aOR]) 1.4; 95% confidence interval [CI], 1.1-1.8). In women with obesity, AH was associated with a higher overall complication rate (aOR 1.8; 95% CI, 1.2-2.6) and VH had a slightly higher risk of intraoperative complications (aOR 4.4; 95% CI, 1.2-15.8), both in comparison with RTLH. Women with obesity had a higher rate of conversion to AH with conventional minimally invasive hysterectomy (TLH: aOR 28.2; 95% CI, 6.4-124.7 and VH: 17.1; 95% CI, 3.5-83.8, respectively) compared with RTLH. AH, TLH, and VH were associated with a higher risk of blood loss >500 mL than RTLH (aOR 11.8; 95% CI, 3.4-40.5; aOR 8.5; 95% CI, 2.5-29.5; and aOR 5.8; 95% CI, 1.5-22.8, respectively) in women with obesity.

Conclusion: The use of RTLH may lower the risk of conversion rates and intraoperative bleeding in women who are obese compared with other modes of hysterectomy.
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http://dx.doi.org/10.1016/j.jmig.2020.04.038DOI Listing
February 2021

Risk-factors for continuous long-term use of prescription opioid drugs 3 years after hysterectomy: A nationwide cohort study.

Acta Obstet Gynecol Scand 2020 08 6;99(8):1057-1063. Epub 2020 Mar 6.

Department of Clinical Science and Education, Södersjukhuset University Hospital, Karolinska Institutet, Stockholm, Sweden.

Introduction: The widespread misuse of prescription pain medication, including opioids, has serious public health implications. Postoperative pain is a risk factor for persistent or chronic pain unless treated effectively. There are only a few studies that have assessed the use of opioid-containing drugs after gynecological surgery and most of these usually have a short follow-up period. The aim of this study was to identify risk-factors for long-term use of prescription opioid drugs following hysterectomy.

Material And Methods: We performed a nationwide cohort study based on prospectively collected data. Information from two population-based registers, the Swedish National Quality Register of Gynecological Surgery and the Swedish National Drug Register, was linked. The study population consisted of women with benign disease undergoing a total hysterectomy from 1 January 2012 until 31 December 2015. To identify long-term changes in prescription of opioids, individual data were collected from 1 year prior to to 3 years after surgery between 2011 and 2018. Data analysis was performed using multivariable logistic regression models.

Results: The population included 17 385 women having had hysterectomy for benign disease. Of these women, 4233 (24.4%) were prescribed analgesics continuously for 3 years postoperatively and 1225 (7.1%) used opioids long term. Perioperative predictors of opioid use 3 years after surgery included a diagnosis of adenomyosis (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.2-2.7) and preoperative use of opioids (aOR 29.6, 95% CI 19.7-44.4), psycho- (aOR 3.5, 95% CI 2.4-5.0) and neuroactive drugs (aOR 1.8, 95% CI 1.0-3.1). For women with no opioid prescription preoperatively (n = 260, 1.5%), mild (aOR 2.8, 95% CI 1.1-7.3) and severe (3.0% vs 6.2%: aOR 6.4, 95% CI 1.4-20.0) postoperative complications and preoperative prescription of psychoactive drugs (aOR 4.6, 95% CI 1.9-10.7) were associated with long-term use of drugs containing opioids.

Conclusions: Long-term use of prescription opioids after hysterectomy is common and is, among other risk factors, strongly associated with preoperative use of opioids, as well as psychoactive drugs and adenomyosis. To avoid opioid misuse disorders among women at risk for long-term opioid drug prescriptions after hysterectomy, further studies and strategies are needed.
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http://dx.doi.org/10.1111/aogs.13826DOI Listing
August 2020

Perineorrhaphy Compared With Pelvic Floor Muscle Therapy in Women With Late Consequences of a Poorly Healed Second-Degree Perineal Tear: A Randomized Controlled Trial.

Obstet Gynecol 2020 02;135(2):341-351

Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, and the Division of Obstetrics and Gynecology, Södersjukhuset, Stockholm, Sweden.

Objective: To evaluate outcomes after pelvic floor muscle therapy, as compared with perineorrhaphy and distal posterior colporrhaphy, in the treatment of women with a poorly healed second-degree obstetric injury diagnosed at least 6 months postpartum.

Methods: We performed a single center, open-label, randomized controlled trial. After informed consent, patients with a poorly healed second-degree perineal tear at minimum 6 months postpartum were randomized to either surgery or physical therapy. The primary outcome was treatment success, as defined by Patient Global Impression of Improvement, at 6 months. Secondary outcomes included the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the Hospital Anxiety and Depression Scale. Assuming a 60% treatment success in the surgery group and 20% in the physical therapy group, plus anticipating a 20% loss to follow-up, a total of 70 patients needed to be recruited.

Results: From October 2015 to June 2018, 70 of 109 eligible patients were randomized, half into surgery and half into tutored pelvic floor muscle therapy. The median age of the study group was 35 years, and the median duration postpartum at enrollment in the study was 10 months. There were three dropouts in the surgery group postrandomization. In an intention-to-treat analysis, with worst case imputation of missing outcomes, subjective global improvement was reported by 25 of 35 patients (71%) in the surgery group compared with 4 of 35 patients (11%) in the physical therapy group (treatment effect in percentage points 60% [95% CI 42-78%], odds ratio 19 [95% CI 5-69]). The surgery group was superior to physical therapy regarding all secondary endpoints.

Conclusion: Surgical treatment is effective and superior to pelvic floor muscle training in relieving symptoms related to a poorly healed second-degree perineal tear in women presenting at least 6 months postpartum.

Clinical Trial Registration: ClinicalTrials.gov, NCT02545218.
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http://dx.doi.org/10.1097/AOG.0000000000003653DOI Listing
February 2020

Associations Between Childbirth and Urinary Incontinence After Midurethral Sling Surgery.

Obstet Gynecol 2018 02;131(2):297-303

Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, and the Division of Obstetrics and Gynecology, Södersjukhuset, Stockholm, Sweden.

Objective: To assess whether subsequent childbirths affect the outcomes of midurethral sling surgery with regard to stress urinary incontinence (SUI).

Methods: In this population-based cohort study, we used the validated Swedish nationwide health care registers (the Patient Register and the Medical Birth Register) to identify women with a delivery after midurethral sling surgery (n=207, study group). From the same registers we then randomly identified a control group who had no deliveries after their midurethral sling procedure (n=521, control group). The women in the control group were matched to the women in the study group by age and year of surgery. The Urogenital Distress Inventory and the Incontinence Impact Questionnaire were sent out to the study population. Symptomatic SUI was defined as the primary outcome. Secondary outcomes included the total Urogenital Distress Inventory score, Urogenital Distress Inventory subscale scores, and Incontinence Impact Questionnaire scores.

Results: A total of 728 women were eligible for the study. The response rate was 74%; 163 in the study group (64 with vaginal delivery and 95 with cesarean delivery) and 374 women in the control group were included in the analysis. The rate of SUI (primary outcome) was 36 of 163 (22%) in the study group and 63 of 374 (17%) in the control group. In a multivariate regression analysis of the primary outcome, we found no significant difference between the groups (odds ratio [OR] 1.2, 95% CI 0.7-2.0). Vaginal childbirth after midurethral sling surgery did not increase the risk of SUI compared with cesarean delivery (22% vs 22%, OR 0.6, 95% CI 0.2-1.4). There were no significant differences in Urogenital Distress Inventory and Incontinence Impact Questionnaire scores between any of the groups.

Conclusion: Childbirth after a midurethral sling procedure is not associated with an increased risk of patient-reported SUI, and continence status is not affected by the mode of a subsequent delivery.
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http://dx.doi.org/10.1097/AOG.0000000000002445DOI Listing
February 2018

Cervical amputation versus vaginal hysterectomy: a population-based register study.

Int Urogynecol J 2017 Feb 16;28(2):257-266. Epub 2016 Aug 16.

Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet and the Division of Obstetrics and Gynecology at Södersjukhuset, Stockholm, Sweden.

Introduction And Hypothesis: Surgical management of uterine prolapse varies greatly and recently uterus-preserving techniques have been gaining popularity. The aim of this study was to compare patient-reported outcomes after cervical amputation versus vaginal hysterectomy, with or without concomitant anterior colporrhaphy, in women suffering from pelvic organ prolapse.

Method: We carried out a population-based longitudinal cohort study with data from the Swedish National Quality Register for Gynecological Surgery. Between 2006 and 2013, a total of 3,174 patients with uterine prolapse were identified, who had undergone primary surgery with either cervical amputation or vaginal hysterectomy, with or without concomitant anterior colporrhaphy. Pre- and postoperative prolapse-related symptoms and patient satisfaction were assessed, in addition to complications and adverse events. Between-group comparisons were performed using univariate and multivariate logistic regression.

Results: There were no differences between the two groups in neither symptom relief nor patient satisfaction. In both groups a total of 81 % of the women reported the absence of vaginal bulging 1 year after surgery and a total of 89 % were satisfied with the result of the operation. The vaginal hysterectomy group had a higher rate of severe complications than the cervical amputation group, 1.9 % vs 0.2 % (p < 0.001). The vaginal hysterectomy group also had a longer duration of surgery and greater perioperative blood loss, in addition to longer hospitalization.

Conclusions: Cervical amputation seems to perform equally well in comparison to vaginal hysterectomy in the treatment of uterine prolapse, but with less morbidity and a lower rate of severe complications.
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http://dx.doi.org/10.1007/s00192-016-3119-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5306059PMC
February 2017

Does the choice of suture material matter in anterior and posterior colporrhaphy?

Int Urogynecol J 2016 Sep 2;27(9):1357-65. Epub 2016 Mar 2.

Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet and the Division of Obstetrics and Gynecology at Södersjukhuset, 11832 Södersjukhuset, Stockholm, Sweden.

Introduction And Hypothesis: The optimal suture material in traditional prolapse surgery is still controversial. Our aim was to investigate the effect of using sutures with rapid (RA) or slow (SA) absorption, on symptomatic recurrence after anterior and posterior colporrhaphy.

Methods: A population-based longitudinal cohort study with data from the Swedish National Quality Register for Gynecological Surgery. A total of 1,107 women who underwent primary anterior colporrhaphy and 577 women who underwent primary posterior colporrhaphy between September 2012 and September 2013 were included. Two groups in each cohort were created based on which suture material was used. Pre- and postoperative prolapse-related symptoms and patient satisfaction were assessed.

Results: We found a significantly lower rate of symptomatic recurrence 1 year after anterior colporrhaphy in the SA suture group compared with the RA suture group, 50 out of 230 (22 %) vs 152 out of 501 (30 %), odds ratio 1.6 (CI 1.1-2.3; p = 0.01). The SA group also had a significantly higher patient satisfaction rate, 83 % vs 75 %, odds ratio 1.6 (CI 1.04-2.4), (p = 0.03). Urgency improved significantly more in the RA suture group (p < 0.001). In the posterior colporrhaphy cohort there was no significant difference between the suture materials.

Conclusions: This study indicates that the use of slowly absorbable sutures decreases the odds of having a symptomatic recurrence after an anterior colporrhaphy compared with the use of rapidly absorbable sutures. However, the use of RA sutures may result in less urgency 1 year postoperatively. In posterior colporrhaphy the choice of suture material does not affect postoperative symptoms.
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http://dx.doi.org/10.1007/s00192-016-2981-0DOI Listing
September 2016

Clinical efficacy of a trocar-guided mesh kit for repairing lateral defects.

Int Urogynecol J 2013 Feb 16;24(2):249-54. Epub 2012 Jun 16.

Division of Obstetrics and Gynaecology, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.

Introduction And Hypothesis: The optimal surgery for lateral defects is not well defined. Our objective was to assess the effects of anterior trocar-guided transvaginal mesh repair versus anterior colporrhaphy in women with lateral defects.

Methods: This subanalysis from a randomized controlled trial of mesh kit versus anterior colporrhaphy assessed 99 patient diagnosed at baseline with lateral defects in the anterior vaginal wall. Thirty-nine patients underwent anterior colporrhaphy and 60 anterior trocar-guided transvaginal mesh surgery.

Results: One year after surgery, a persistent lateral defect was significantly more common after colporrhaphy compared with transvaginal mesh [11/32 (34.4 %) vs 1/42 (2.4 %), risk ratio (RR) 14.4, 95 % confidence interval (CI) 2.0-106.1; P < 0.001)] However, there were no significant differences between treatment groups with regard to subjective symptoms as reflected by the overall Urogenital Distress Inventory scores, with mean difference from baseline 37.3 ± 50.6 in the colporrhaphy group vs 39.0 ± 45.8 in the mesh group (p = 0.61).

Conclusions: Use of a transvaginal mesh kit increases the odds for anatomical correction of lateral defects compared with anterior colporrhaphy but does not necessarily improve lower urinary tract symptoms.
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http://dx.doi.org/10.1007/s00192-012-1833-9DOI Listing
February 2013

Risk factors for mesh complications after trocar guided transvaginal mesh kit repair of anterior vaginal wall prolapse.

Neurourol Urodyn 2012 Sep 19;31(7):1165-9. Epub 2012 Apr 19.

Division of Surgery and Urology, Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden.

Aims: To identify risk factors for mesh exposures after anterior pelvic organ prolapse repair using a standardized trocar guided polypropylene mesh kit.

Methods: A secondary risk analysis combining patients from two prospective multicenter studies. Main outcome was clinical host-vs-implant reactions one year after surgery using a macroscopic inflammatory scale.

Results: 353 patients were included in the study. Mean age at surgery was 65.3 (± 9.6 SD) years and surgery was performed as a primary procedure in 224/353 (63.5%) patients. Mesh exposures, of which the majority were mild-moderate, occurred in a total of 30/349 patients (8.6%). Multivariate logistic regression showed increased odds for mesh exposures for women who smoked before surgery (OR 3.48, 95% CI 1.18-10.28), who had given birth to more than two children (OR 2.64, 95% CI 1.07-6.51) and those with somatic inflammatory disease (OR 5.11, 95% CI 1.17-22.23). Age, body mass index, and menopausal status showed no significant association with clinical mesh exposures.

Conclusions: Smoking, multiple childbirth, and somatic inflammatory disease are possible risk factors for mesh exposure after trocar guided mesh kit surgery for anterior pelvic organ prolapse. Preoperative smoking cessation may decrease the risk for exposures.
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http://dx.doi.org/10.1002/nau.22231DOI Listing
September 2012

Short-term natural history in women with symptoms indicative of pelvic organ prolapse.

Int Urogynecol J 2011 Apr 20;22(4):461-8. Epub 2010 Oct 20.

Department of Obstetrics and Gynaecology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.

Introduction And Hypothesis: Information about the natural history of pelvic organ prolapse (POP) is scarce.

Methods: This was a prospective cohort study of 160 women (mean age 56 years), whose answers in a population-based survey investigation indicated presence of symptomatic prolapse (siPOP), and 120 women without siPOP (mean age 51 years).

Results: Follow-up questionnaire was completed by 87%, and 67% underwent re-examination according to pelvic organ prolapse quantification (POP-Q) system after 5 years. Among re-examining siPOP women, 47% had an unchanged POP-Q stage, 40% showed regression, and 13% showed progression. The key symptom "feeling of a vaginal bulge" remained unchanged in 30% of women with siPOP, 64% improved by at least one step on our four-step rating scale, and 6% deteriorated. Among control women, siPOP developed in 2%. No statistically significant relationship emerged between changes in anatomic status and changes in investigated symptoms.

Conclusion: Only a small proportion of women with symptomatic POP get worse within 5 years.
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http://dx.doi.org/10.1007/s00192-010-1305-zDOI Listing
April 2011

Effects of anterior trocar guided transvaginal mesh surgery on lower urinary tract symptoms.

Neurourol Urodyn 2010 Nov;29(8):1419-23

Division of Obstetrics and Gynaecology, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.

Aims: To assess the effects of trocar guided transvaginal mesh on lower urinary tract symptoms after anterior vaginal wall prolapse repair.

Methods: One hundred twenty-one patients undergoing anterior transvaginal mesh surgery was prospectively evaluated at baseline and 1 year after surgery using the urogenital distress inventory (UDI).

Results: Overall UDI scores declined from 91 before surgery to 31 one year after surgery (P < 0.001). UDI subscales for obstructive and irritative symptoms improved 1 year after surgery (P < 0.001 for both) while stress symptoms did not (P = 0.11).

Conclusion: Trocar guided transvaginal mesh surgery for anterior vaginal wall prolapse was associated with an overall resolution of most symptoms associated with overactive bladder syndrome and bladder outlet obstruction. These beneficial effects should be weighed against an increased risk for stress urinary incontinence related to the procedure.
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http://dx.doi.org/10.1002/nau.20880DOI Listing
November 2010

Urodynamic assessment of anterior vaginal wall surgery: a randomized comparison between colporraphy and transvaginal mesh.

Neurourol Urodyn 2010 Apr;29(4):527-31

Division of Obstetrics and Gynaecology, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.

Aims: To investigate the urodynamic effects of anterior vaginal wall prolapse surgery using either trocar guided transvaginal mesh or colporraphy.

Methods: A prospective, randomized multicenter trial enrolling 50 patients: 27 underwent anterior colporrhaphy and 23 anterior trocar guided transvaginal mesh. Urodynamic assessment was performed pre- and two months postoperatively.

Results: De novo stress urinary incontinence was significantly more common after trocar guided transvaginal mesh surgery compared to colporraphy. In comparison to baseline urodynamics, transvaginal mesh surgery resulted in a significant decrease in maximal urethral closing pressures (MUCP) whereas conventional anterior colporraphy had no significant effect on urodynamic parameters.

Conclusion: Trocar guided transvaginal mesh of anterior vaginal wall prolapse results in a lowering of MUCPs and increases the risk for de novo stress urinary incontinence compared to colporraphy.
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http://dx.doi.org/10.1002/nau.20811DOI Listing
April 2010