Randomised clinical trial of suture compared withadhesive strip for skin closure after HRT implant

Sir,The paper by Daniel Selo-Ojeme and K.B. Lim1 has concluded

that adhesive strips for implant skin incision closure is notrecommended. They made no reference to the type of localanaesthetic which was used in their study. For the last five years,I have used bupivacaine hydrochloride with adrenaline (5 Ag/mL)for subcutaneous infiltration prior to inserting the hormoneimplant. Before this I used lignocaine hydrochloride withoutadrenaline. When using lignocaine, I always used sutures becauseof bleeding. However, having changed to bupivacaine withadrenaline, blood loss is insignificant at the time of the incisionand adhesive strips are used as routine. I do not have to insert asuture since changing to bupivacaine with adrenaline and Ihave had no post-treatment haemorrhage. I would recommendthat the authors consider a randomised trial comparing these twotypes of local anaesthetic combined with adhesive strips for skinclosure.

Reference

1. Selo-Ojeme DO, Lim KB. Randomised clinical trial of suture compared

with adhesive strip for skin closure after HRT implant. Br J Obstet

Gynaecol 2002;109:1178– 1180.

Paul ByrneRotunda Hospital, Dublin, Ireland

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Cost effectiveness of pre-operative gonadotrophinreleasing analogues for women with uterine fibroidsundergoing hysterectomy or myomectomy

Sir,We agree with Farquhar et al.1 that pre-operative gonadotro-

phin releasing analogues (GnRHa) are not cost effective2, but wedisagree with the model they based their analysis on.

Their economic evaluation was based on effectiveness datafrom a systematic review2. In the review of 21 randomisedcontrolled trials, use of GnRHa resulted in a significant reductionin uterine size of up to 50%. But despite this, the overallprobability of having a vaginal hysterectomy compared with anabdominal one was only 38% versus 12%. Based on thesefigures, they calculated that with pretreatment the extra cost ofperforming a vaginal rather than an abdominal hysterectomy wasNZ$4577. But only one paper specified uterine size3 and in thisstudy the authors did not attempt a vaginal hysterectomy if theuterus was > 14 weeks of gestation. In reality, vaginal hyster-ectomy can be performed in 95% of cases with uteri of 14 to 18weeks of gestation4, which means that GnRH analogues arerarely required prior to surgery just to make a vaginal procedurepossible. We reserve GnRHa pretreatment to women with uteri>18 weeks of gestation equivalent, or those who are anaemic andwe wish to render them amenorrhoeic to improve their iron storesand haemoglobin concentration prior to surgery.

Similarly, if abdominal hysterectomy or myomectomy isdone in the presence of a grossly enlarged uterus, a midlineincision can generally be avoided by utilising a Maylard musclesplitting incision or the similar Cherney incision, both of which

are done transversely6,7. Again, there is rarely a need forGnRHa pretreatment just to allow a low transverse incision tobe utilised.

It is better for the gynaecologist to learn surgical techniquessuch as uterine bisection, morcellation, vaginal myomectomy andcoring, as well as different types of abdominal incisions ratherthan reaching for the prescription pad. Using these techniques, amuch higher proportion of hysterectomies could be done vaginallywithout any hormonal preparation5, and fewer would require anunsightly vertical incision.

References

1. Farquhar C, Brown P, Furness S. Cost effectiveness of pre-operative

gonadotrophin releasing analogues for women with uterine fibroids

undergoing hysterectomy or myomectomy. Br J Obstet Gynaecol

2002;109:1273– 1280.

2. Lethaby A, Vollenhoven B, Sowter M. Pre-operative GnRHa analogue

therapy before hysterectomy or myomectomy for uterine fibroids.

Cochrane Library, Issue 2, 2001.

3. Stovall T, Summit R, Washburn S, Ling F. Gonadotrophin-releasing

hormone agonist use before hysterectomy. Am J Obstet Gynecol

170:1744– 1751.

4. Magos AL, Bournas N, Sinha R, O’Connor H. Vaginal hysterectomy

for the large uterus. Br J Obstet Gynaecol 1996;103:246–251.

5. Davies A, Vizza E, Bournas N, O’Connor H, Magos A. How to increase

the proportion of hysterectomies performed vaginally. Am J Obstet

Gynecol 1998;179:1008– 1012.

6. Maylard AE. Direction of the abdominal muscles. BMJ 1907;ii:

895– 901.

7. Cherney LS. A modified transverse incision for lower abdominal

operations. Surg Gynecol Obstet 1941;72:92– 95.

Malini Sharma, Lucie Buck, George Mastrogamvrakis,Konstantinos Kontos, Adam Magos & Alex TaylorUniversity Department of Obstetrics and Gynaecology, RoyalFree Hospital, London, UK

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AUTHOR’S REPLY

Sir,The economic analysis was based on a systematic review of

21 studies of GnRH analogues in women with uterine fibroids.Although some studies have reported high proportions of vaginalhysterectomy, the pooled results were only 38% even whenpretreatment with GnRH analogues was given. In women withuterine fibroids greater than 18 weeks, only 2 of 30 had vaginalhysterectomy even when pre-operative GnRH analogues weregiven and in the study reporting on women with fibroids between14 and 18 weeks, 80% of hysterectomies were vaginal after pre-operative treatment with GnRH analogues1. While 95% ofvaginal hysterectomies may be achievable in the hands of some(such as the authors of the letter), this is certainly not theexperience of the majority of gynaecologists and many haveconsidered shrinking fibroids prior to surgery.

The purpose of our report was to establish whether or not itwas cost effective to shrink fibroids and the conclusions werethat it was not. There are many valid reasons to avoid abdominalsurgery and concentrating on improving vaginal surgical skills iscommendable.

D RCOG 2003 Br J Obstet Gynaecol 110, pp. 710–714

CORRESPONDENCE712