BJOG Exchange
example, uses much higher hospital accommodation costs than our study and assumes a constant volume of ten cases per week over 10 years.3 With a mean skin-to-skin time of 240 minutes for robot-assisted surgery, maintaining such a volume would require constant robot use for 5 days a week with no allowance for downtime or robot failure. We used expert clinical opinion to determine that 300 procedures per annum was a more realistic volume of operations in our setting, and that 7 years was a more typical lifespan for the robotic surgical system. Also, evidence of clinical effectiveness should not be conflated with evidence of cost-effectiveness. Any improvement in outcomes must be counterbalanced by the significant costs associated with the purchase and maintenance of the robot system, as well as the disposable instruments. An economic evaluation should incorporate these costs appropriately. The cost per procedure associated with the robotic system may be reduced by using the system for multiple indications, although this ties the estimate of costeffectiveness to the use of the system for other procedures that may or may not be cost-effective. We advocate the consideration of all the available evidence rather than a subset of the available evidence. The cost-effectiveness of robot-assisted surgery relative to open surgery and traditional laparoscopic surgery for certain indications should be consistently demonstrated in a number of good-quality studies. The adoption of an expensive technology should not be decided on the basis of selected evidence, which may or may not be applicable to the setting where the system will be introduced. Disclosure of interests The authors have no conflict of interest to declare. & References 1 Teljeur C, O’Neill M, Moran PS, Harrington P, Flattery M, Murphy L, et al. Economic
evaluation of robot-assisted hysterectomy: a cost-minimisation analysis. BJOG 2014; 121:1546–53. 2 O’Neill M, Moran PS, Teljeur C, O’Sullivan OE, O’Reilly B, Hewitt M, et al. Robot-assisted hysterectomy compared to open and laparoscopic approaches: systematic review and meta-analysis. Arch Gynecol Obstet 2013;287:907–18. 3 Lau S, Vaknin Z, Ramana-Kumar AV, Halliday D, Franco EL, Gotlieb WH. Outcomes and cost comparisons after introducing a robotics programme for endometrial cancer surgery. Obstet Gynecol 2012;119:717–24.
C Teljeur, M O’Neill, PS Moran, P Harrington, L Murphy, & M Ryan Health Information and Quality Authority, Dublin, Ireland Accepted 22 December 2014. DOI: 10.1111/1471-0528.13309
Re: Removable uterine compression sutures for postpartum haemorrhage
Two questions Sir, Uterine compression suture (UCS) is one of the most innovative obstetric procedures, but it is not without adverse events, such as uterine necrosis or infertility, the main culprit of which is remaining threads.1 Zhang et al.2 solved this problem: the threads of BLynch or Hayman UCS were pulled out of the vagina, the knot was cut, and the threads were removed from the vaginal side after an average of 21.6 hours. Publication delay prevented Zhang et al. from citing our recent article ‘New prophylaxis methods for adverse events of uterine compression sutures: Removing compression threads’, in which I proposed a similar concept.3 The reports differ as follows: (1) Zhang et al. tied the knot within the uterine cavity; (2) they devised a cannula to retrieve the thread; and (3) importantly, they actually performed this procedure, whereas I only proposed it. As I, along
ª 2015 Royal College of Obstetricians and Gynaecologists
with other BJOG readers, have no experience of performing this procedure I wish to ask Zhang et al. the following two questions. First, how far could the knot be pulled down to the vagina when it was incised? I wonder about the degree of loosening of the knot after 21.6 hours postpartum. The fundamental concept of the ‘thread removal’ strategy is based on uterine involution: the uterus contracts postpartum and thus (1) the UCS no longer compresses the uterine cavity, and in fact uterine compression is no longer needed, and (2) the knot becomes loosened to the extent that it can be retrieved and cut from the vagina. If the loosening of the knot (movability) is relatively marked (i.e. >3–4 cm), specific apparatus such as a cannula may not be needed, and thus the thread can be removed more easily. Was cutting the knot and removing the thread difficult? Could these actions be performed even without the aid of a cannula? Second, how were the threads placed in the vagina? If UCS has already been performed, this may have narrowed the caudal uterine portion. In some caesarean sections, especially for placenta praevia, the cervical ostium is closed, or at least narrow. Thus, placing the thread in the vagina may be difficult. Two methods may be possible: (1) a vaginal ? uterine route, in which small forceps are inserted from the vagina through the cervix, and then the thread is grasped, with the thread being pulled down in the vagina; or (2) a uterine ? vaginal route, in which the thread is tied (connected) to some narrow tube (such as a Hagar dilator), and the tube together with the thread is pushed down to the vagina. I eagerly await a response from Zhang et al. As previously described,3 two other methods may be possible to remove threads: laparoscopic and abdominal. Laparoscopic removal has already been performed.4 Abdominal removal remains theoretical. I hope that Zhang et al. and other researchers will attempt
755
BJOG Exchange
it, and report on their experience of thread removal, not only vaginally but also laparoscopically and abdominally. The thread removal is crucial. For this, Zhang et al.’s procedure is simple, clear, and promising. & References 1 Matsubara S, Yano H, Ohkuchi A, Kuwata T, Usui R, Suzuki M. Uterine compression sutures for postpartum hemorrhage: an overview. Acta Obstet Gynecol Scand 2013;92:378–85.
756
2 Zhang Z, Liu C, Yu N, Guo W. Removable uterine compression sutures for postpartum haemorrhage. BJOG 2014;122:429–33. 3 Matsubara S. New prophylaxis methods for adverse events of uterine compression sutures: removing compression threads. Acta Obstet Gynecol Scand 2014;93:1069–70. 4 Hashida O, Hayashi M, Furuno A, Saito K, Takayasu Y, Ishikawa M. Laparoscopic removal of the threads for uterine compression suture: possible prophylaxis of uterine synechiae. Kanto J Obst Gynec (Tokyo) 2013;50:167–70. (in Japanese).
S Matsubara Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Japan Note: The authors of the article referred to in this letter were invited to reply, but no response was received.
Accepted 16 September 2014. DOI: 10.1111/1471-0528.13190
ª 2015 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
example, uses much higher hospital accommodation costs than our study and assumes a constant volume of ten cases per week over 10 years.3 With a mean skin-to-skin time of 240 minutes for robot-assisted surgery, maintaining such a volume would require constant robot use for 5 days a week with no allowance for downtime or robot failure. We used expert clinical opinion to determine that 300 procedures per annum was a more realistic volume of operations in our setting, and that 7 years was a more typical lifespan for the robotic surgical system. Also, evidence of clinical effectiveness should not be conflated with evidence of cost-effectiveness. Any improvement in outcomes must be counterbalanced by the significant costs associated with the purchase and maintenance of the robot system, as well as the disposable instruments. An economic evaluation should incorporate these costs appropriately. The cost per procedure associated with the robotic system may be reduced by using the system for multiple indications, although this ties the estimate of costeffectiveness to the use of the system for other procedures that may or may not be cost-effective. We advocate the consideration of all the available evidence rather than a subset of the available evidence. The cost-effectiveness of robot-assisted surgery relative to open surgery and traditional laparoscopic surgery for certain indications should be consistently demonstrated in a number of good-quality studies. The adoption of an expensive technology should not be decided on the basis of selected evidence, which may or may not be applicable to the setting where the system will be introduced. Disclosure of interests The authors have no conflict of interest to declare. & References 1 Teljeur C, O’Neill M, Moran PS, Harrington P, Flattery M, Murphy L, et al. Economic
evaluation of robot-assisted hysterectomy: a cost-minimisation analysis. BJOG 2014; 121:1546–53. 2 O’Neill M, Moran PS, Teljeur C, O’Sullivan OE, O’Reilly B, Hewitt M, et al. Robot-assisted hysterectomy compared to open and laparoscopic approaches: systematic review and meta-analysis. Arch Gynecol Obstet 2013;287:907–18. 3 Lau S, Vaknin Z, Ramana-Kumar AV, Halliday D, Franco EL, Gotlieb WH. Outcomes and cost comparisons after introducing a robotics programme for endometrial cancer surgery. Obstet Gynecol 2012;119:717–24.
C Teljeur, M O’Neill, PS Moran, P Harrington, L Murphy, & M Ryan Health Information and Quality Authority, Dublin, Ireland Accepted 22 December 2014. DOI: 10.1111/1471-0528.13309
Re: Removable uterine compression sutures for postpartum haemorrhage
Two questions Sir, Uterine compression suture (UCS) is one of the most innovative obstetric procedures, but it is not without adverse events, such as uterine necrosis or infertility, the main culprit of which is remaining threads.1 Zhang et al.2 solved this problem: the threads of BLynch or Hayman UCS were pulled out of the vagina, the knot was cut, and the threads were removed from the vaginal side after an average of 21.6 hours. Publication delay prevented Zhang et al. from citing our recent article ‘New prophylaxis methods for adverse events of uterine compression sutures: Removing compression threads’, in which I proposed a similar concept.3 The reports differ as follows: (1) Zhang et al. tied the knot within the uterine cavity; (2) they devised a cannula to retrieve the thread; and (3) importantly, they actually performed this procedure, whereas I only proposed it. As I, along
ª 2015 Royal College of Obstetricians and Gynaecologists
with other BJOG readers, have no experience of performing this procedure I wish to ask Zhang et al. the following two questions. First, how far could the knot be pulled down to the vagina when it was incised? I wonder about the degree of loosening of the knot after 21.6 hours postpartum. The fundamental concept of the ‘thread removal’ strategy is based on uterine involution: the uterus contracts postpartum and thus (1) the UCS no longer compresses the uterine cavity, and in fact uterine compression is no longer needed, and (2) the knot becomes loosened to the extent that it can be retrieved and cut from the vagina. If the loosening of the knot (movability) is relatively marked (i.e. >3–4 cm), specific apparatus such as a cannula may not be needed, and thus the thread can be removed more easily. Was cutting the knot and removing the thread difficult? Could these actions be performed even without the aid of a cannula? Second, how were the threads placed in the vagina? If UCS has already been performed, this may have narrowed the caudal uterine portion. In some caesarean sections, especially for placenta praevia, the cervical ostium is closed, or at least narrow. Thus, placing the thread in the vagina may be difficult. Two methods may be possible: (1) a vaginal ? uterine route, in which small forceps are inserted from the vagina through the cervix, and then the thread is grasped, with the thread being pulled down in the vagina; or (2) a uterine ? vaginal route, in which the thread is tied (connected) to some narrow tube (such as a Hagar dilator), and the tube together with the thread is pushed down to the vagina. I eagerly await a response from Zhang et al. As previously described,3 two other methods may be possible to remove threads: laparoscopic and abdominal. Laparoscopic removal has already been performed.4 Abdominal removal remains theoretical. I hope that Zhang et al. and other researchers will attempt
755
BJOG Exchange
it, and report on their experience of thread removal, not only vaginally but also laparoscopically and abdominally. The thread removal is crucial. For this, Zhang et al.’s procedure is simple, clear, and promising. & References 1 Matsubara S, Yano H, Ohkuchi A, Kuwata T, Usui R, Suzuki M. Uterine compression sutures for postpartum hemorrhage: an overview. Acta Obstet Gynecol Scand 2013;92:378–85.
756
2 Zhang Z, Liu C, Yu N, Guo W. Removable uterine compression sutures for postpartum haemorrhage. BJOG 2014;122:429–33. 3 Matsubara S. New prophylaxis methods for adverse events of uterine compression sutures: removing compression threads. Acta Obstet Gynecol Scand 2014;93:1069–70. 4 Hashida O, Hayashi M, Furuno A, Saito K, Takayasu Y, Ishikawa M. Laparoscopic removal of the threads for uterine compression suture: possible prophylaxis of uterine synechiae. Kanto J Obst Gynec (Tokyo) 2013;50:167–70. (in Japanese).
S Matsubara Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Japan Note: The authors of the article referred to in this letter were invited to reply, but no response was received.
Accepted 16 September 2014. DOI: 10.1111/1471-0528.13190
ª 2015 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
![[Risk of uterine synechiae following uterine compression sutures during postpartum haemorrhage].](/assets/img/hold.png)
