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  • 1. Billfeldt, Nina K.
    et al.
    Borgfeldt, Christer
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Stjerndahl, Jan-Henrik
    Ankardal, Maud
    A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery2018In: European Journal of Obstetrics, Gynecology, and Reproductive Biology, ISSN 0301-2115, E-ISSN 1872-7654, Vol. 222, p. 113-118Article in journal (Refereed)
    Abstract [en]

    Objective: The aim was to evaluate surgical routes for benign hysterectomy in a Swedish population, including abdominal and minimally invasive surgery. Study design: Prospectively collected data from the Swedish National GynOp Registry 2009-2015: 13 806 hysterectomy cases were included: abdominal (AH, n = 7485), vaginal (VH, n = 3767), conventional laparoscopic (LH, n = 1539) and robotically-assisted (RAH, n = 1015). Results: The VH group had the shortest operation time at 75 min, AH 97 min and RAH 104 min. LH was longest at 127 min (p < 0.005). The mean estimated blood loss was higher in the AH group (250 ml) compared to all minimally invasive surgery (MIS, 65-172 ml): p < 0.005). Conversion rates were 10% for LH, 4.8% for VH and 1.6% for RAH (p < 0.005). Hospitalization and patient reported time to normal activities of daily living (ADL) were longer for AH compared to MIS (p < 0.005). Time to return to work was eight days longer in the AN group (35 days) compared with the MIS groups (p < 0.005). Complications were fewest in the VH group at 5.4% compared with AH 7.6% and RAH 8.7% (both p < 0.001), but did not significantly differ from the LH group at 6.6%. Overall patient satisfaction was reported to be 86-94% one year after surgery. Conclusion: Women operated on for benign hysterectomy with minimally invasive methods in Sweden 2009-2015 had reduced length of hospitalization, as well as time to resuming normal ADL and return to work, compared to AH. Postoperative outcome measures were improved by minimally invasive methods and MIS should preferably be used.

  • 2. Bohlin, Katja S.
    et al.
    Ankardal, Maud
    Stjerndahl, Jan-Henrik
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Milsom, Ian
    Influence of the modifiable life-style factors body mass index and smoking on the outcome of hysterectomy2016In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 95, no 1, p. 65-73Article in journal (Refereed)
    Abstract [en]

    Introduction

    The aim of this study was to study the impact of body mass index (BMI) and smoking on the outcome of hysterectomy and whether effects of these factors vary between abdominal, laparoscopic and vaginal hysterectomy.

    Material and methods

    Pre-, per- and postoperative (8 weeks) data were retrieved from the Swedish National Register for Gynecological Surgery on 28 537 hysterectomies performed because of a benign indication between 2004 and 2013. Multivariable logistic regression analyses were used to identify independent factors affecting the rate of complications, presented as adjusted odds ratios (adjOR) with 95% confidence intervals (CI).

    Results

    Overweight and obesity had the strongest impact on complications in the abdominal hysterectomy group. In women with a BMI 30 an increased adjOR could be seen for bleeding >1000 mL (2.90; 95% CI 2.23-3.77), peroperative complications (1.54; 95% CI 1.26-1.88), operation time >120 min (2.67; 95% CI 2.33-3.03), postoperative complications (1.21; 95% CI 1.08-1.34) and postoperative infections (1.73; 95% CI 1.50-1.99). With vaginal hysterectomy, the effect of BMI 30 could be seen in relation to excessive bleeding >500 mL (1.63; 95% CI 1.22-2.17) and operative time >120 min (2.00; 95% CI 1.60-2.50). With laparoscopic hysterectomy (LH), a BMI 30 had a higher adjOR for prolonged surgery (1.71; 95% CI 1.30-2.26). Smokers had an increased risk of postoperative infection in the abdominal hysterectomy (1.23; 95% CI 1.07-1.40) and vaginal hysterectomy groups (1.21; 95% CI 1.02-1.43) but not in the LH group.

    Conclusions

    Body mass index and smoking had a negative effect with all hysterectomy approaches but to a lesser extent in vaginal and laparoscopic hysterectomies. This should be taken into consideration in advance of surgery to improve outcome.

  • 3. Bohlin, Katja Stenstrom
    et al.
    Ankardal, Maud
    Nüssler, Emil
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Milsom, Ian
    Factors influencing the outcome of surgery for pelvic organ prolapse2018In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 29, no 1, p. 81-89Article in journal (Refereed)
    Abstract [en]

    Pelvic organ prolapse (POP) surgery is a common gynecological procedure. Our aim was to assess the influence of obesity and other risk factors on the outcome of anterior and posterior colporrhaphy with and without mesh. Data were retrieved from the Swedish National Register for Gynecological Surgery on 18,554 women undergoing primary and repeat POP surgery without concomitant urinary incontinence (UI) surgery between 2006 and 2015. Multivariate logistic regression analyses were used to identify independent risk factors for a sensation of a vaginal bulge, de novo UI, and residual UI 1 year after surgery. The overall subjective cure rate 1 year after surgery was 80% (with mesh 86.4% vs 77.3% without mesh, p < 0.001). The complication rate was low, but was more frequent in repeat surgery that were mainly mesh related. The use of mesh was also associated with more frequent de novo UI, but patient satisfaction and cure rates were higher compared with surgery without mesh. Preoperative sensation of a vaginal bulge, severe postoperative complications, anterior colporrhaphy, prior hysterectomy, postoperative infections, local anesthesia, and body mass index (BMI) 30 were risk factors for sensation of a vaginal bulge 1 year postsurgery. Obesity had no effect on complication rates but was associated increased urinary incontinence (UI) after primary surgery. Obesity had no influence on cure or voiding status in women undergoing repeat surgery. Obesity had an impact on the sensation of a vaginal bulge and the presence of UI after primary surgery but not on complications.

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  • 4.
    Lindkvist, Håkan
    et al.
    Umeå University, Faculty of Science and Technology, Mathematics and Mathematical Statistics.
    Belyaev, Yuri
    Umeå University, Faculty of Science and Technology, Mathematics and Mathematical Statistics.
    Asymptotic properties of estimators in a model of life data with warnings2004In: Communications in Statistics. Theory and Methods., ISSN 0361-0926, Vol. 34, no 2Article in journal (Refereed)
  • 5.
    Lindkvist, Håkan
    et al.
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Belyaev, Yuri K
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    A class of nonparametric tests in the competing riscs model when comparing two samples1995Report (Other academic)
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  • 6.
    Lindkvist, Håkan
    et al.
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Belyaev, Yuri K.
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Asymptotic Properties of Estimators in a Model of Life Data with Warnings2001Report (Other academic)
  • 7.
    Lindkvist, Håkan
    et al.
    Center of Biostatistics, Department of Forest Resource Management and Geomatics, Swedish University of Agricultural Sciences , Umeå, Sweden.
    Belyaev, Yuri K
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Asymptotic properties of estimators in a model of life data with warnings2004In: Communications in Statistics - Theory and Methods, ISSN 0361-0926, E-ISSN 1532-415X, Vol. 34, no 2, p. 461-474Article in journal (Refereed)
    Abstract [en]

    We consider a model where elements of a single type are life tested. All elements are observed up to the time of their failures or censorings. Three types of events are possible to observe during life testing for each element: failure, censoring, and warning, where a warning can only be observed before a failure or before censoring has occurred. It is essential to know if warnings influence subsequent failures. Two subsets of data are simultaneously considered: the first consisting of only the times of the first occurrences of failure, censoring, or warning, and the second consisting of the times for those elements where warnings occurred before failures or censorings. The first subset belongs to the competing risks model, and the second consists of left-truncated data. Estimators of the cumulative hazard function before and after warnings are derived and proved to be consistent, with asymptotic normal distributions. A null hypothesis where the cumulative hazard functions before and after warnings are proportional and a corresponding alternative hypothesis that they are not proportional are defined. Under this null hypothesis an estimator for the constant of proportionality is derived and showed to be strongly consistent. Martingale techniques are used and numerical examples are provided.

  • 8.
    Lindkvist, Håkan
    et al.
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Belyaev, Yuri K
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Testing goodness of fit for life data with warnings1996Report (Other academic)
  • 9.
    Nilsson, Margareta
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lalos, Othon
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    How do urinary incontinence and urgency affect women's sexual life?2011In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 90, no 6, p. 621-628Article in journal (Refereed)
    Abstract [en]

    Objectives. To investigate the impact of urinary incontinence (UI) and urgency on women's sexual life and the prevalence of urinary leakage during sexual activity. A further aim was to explore factors affecting sexual desire and satisfaction with sexual life.

    Design. A semi-structured questionnaire study.

    Setting and Sample. Sexually active women (n=147) aged 18-74years with UI and urgency were recruited from four outpatient clinics.

    Methods. The women completed questionnaires concerning medical history, psychosocial situation, partner relationship, sexual life, and answered the Bristol Female Lower Urinary Tract Symptoms questionnaire. All underwent clinical evaluation.

    Main outcome measures. Prevalence of urinary leakage during sexual activity, factors affecting sexual desire and sexual satisfaction.

    Results. The vast majority considered sexuality to be important in their lives. One-third of the women had urinary leakage during sexual activity. Half reported that sexual life was more or less spoiled due to their UI or urgency, they were worried about having urinary leakage during intercourse and almost two-thirds worried about odor and felt unattractive. The women's dissatisfaction with sexual life was strongly correlated to unsatisfying psychological health, orgasmic disability and worry about urinary leakage during intercourse. Insufficient vaginal lubrication, unsatisfying psychological health, and their partners' ill health were significantly correlated to decreased sexual desire.

    Conclusion. UI and urgency have a negative impact on women's sexual life. Thus, a dialogue about sexual function in women with urinary symptoms should become an integral component in clinical management.

  • 10.
    Nilsson, Margareta
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lalos, Othon
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Impact of female urinary incontinence and urgency on women's and their partners' sexual life2011In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 30, no 7, p. 1276-1280Article in journal (Refereed)
    Abstract [en]

    Aims: To assess the impact of female urinary incontinence (UI) and urgency on women's and their partners' sexual life in sexually active couples and to elucidate the concordance of answers within couples.

    Methods: Women aged 18-74 years with UI and/or urgency (n = 206) were consecutively recruited from four outpatient clinics. Those with a partner (n = 170) completed a questionnaire regarding relationship and sexual life and gave a similar questionnaire to him. The present paper focuses on 99 couples with an active sexual life.

    Results: Twenty-two percent of the men and 43% of the women stated that the female urinary symptoms impaired their sexual life. Forty-nine percent of the women expressed worries about having urinary leakage during sexual activity, but most of their men, 94%, did not. Twenty-three percent of the men and 39% of the women responded that the woman leaked urine during sexual activity. The majority, 84%, of women considered this a problem, but 65% of their partners did not. Except for this disparity, the rest of the answers were significant concordant within the couples.

    Conclusions: Female UI and urgency negatively affected sexual life in almost half of the women and in every fifth partner. A need for information and advice concerning sexual issues due to the woman's urinary disorder was found in one fifth of the couples. The majority of women with urinary leakage during sexual activities considered this as a problem, but most of their partners did not. Overall, the concordance of the answers within the couples was high.

  • 11.
    Nilsson, Margareta
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lalos, Othon
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Löfgren, Mats
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Female urinary incontinence: patient-reported outcomes 1 year after midurethral sling operations2012In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 23, no 10, p. 1353-1359Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION AND HYPOTHESIS: Although midurethral slings have become standard surgical methods to treat stress urinary incontinence (SUI), little is known about women who still have urinary incontinence (UI) after surgery. This study assesses and compares the patient-reported outcome 12 months after tension-free vaginal tape (TVT), tension-free vaginal tape-obturator (TVT-O), and transobturator tape (TOT), with a special focus on women who still have urinary leakage postoperatively.

    METHODS: This study analyzed preoperative and 12-month postoperative data from 3,334 women registered in the Swedish National Quality Register for Gynecological Surgery.

    RESULTS: Among the women operated with TVT (n = 2,059), TVT-O (n = 797), and TOT (n = 478), 67 %, 62 %, and 61 %, respectively, were very satisfied with the result at the 1-year follow-up. There was a significantly higher chance of becoming continent after TVT compared with TOT. In total, 977 women (29 %) still had some form of urinary leakage postoperatively. Among the postoperatively incontinent women who expressed a negative impact of UI on family, social, work, and sexual life preoperatively, considerably fewer reported a negative impact in all domains after surgery. Of those in the postoperatively incontinent group who had coital incontinence preoperatively, 63 % reported a cure of coital incontinence.

    CONCLUSIONS: The proportion of women very satisfied with the result of the operation did not differ between the three groups. TVT had a higher SUI cure rate than did TOT. Despite urinary leakage 1-year postoperatively, half of the women were satisfied with the result of the operation.

  • 12.
    Nilsson, Margareta
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lalos, Othon
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Löfgren, Mats
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Still urinary incontinent after mid-urethral sling operation: what's the impact?2012In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 31, no 6, p. 1059-1060Article in journal (Other academic)
  • 13. Stenström Bohlin, Katja
    et al.
    Ankardal, Maud
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Milsom, Ian
    Factors influencing the incidence and remission of urinary incontinence after hysterectomy2017In: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, Vol. 216, no 1, p. 53.e1-53.e9Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Studies on the influence of body mass index, smoking, and mode of delivery on the occurrence of urinary incontinence after hysterectomy are required to provide women with information about how these factors influence continence after a hysterectomy.

    OBJECTIVE: The aim was to assess the impact of lifestyle factors such as body mass index, smoking, and delivery mode (vaginal/cesarean) on the incidence and remission of urinary incontinence after hysterectomy.

    STUDY DESIGN: This was a cohort study based on pre-, per-, and postoperative (1 year) data retrieved from the Swedish National Register for Gynecological Surgery on 16,182 hysterectomies performed because of a benign indication between 2006 and 2013. Multivariable logistic regression analyses were used to identify independent risk factors for de novo urinary incontinence and postoperative remission of urinary incontinence, presented as adjusted odds ratios with 95% confidence intervals.

    RESULTS: De novo urinary incontinence was reported by 8.5%, remission of urinary incontinence by 13.3%, and residual urinary incontinence by 16.1% after the hysterectomy. A body mass index ≥30 kg/m(2) (odds ratio, 1.63, 95% confidence interval, 1.37-1.94), having undergone a vaginal delivery (odds ratio, 1.40, 95% confidence interval, 1.14-1.86), the presence of daily urge without incontinence prior to surgery (odds ratio, 1.77, 95% confidence interval, 1.47-2.13), and a uterine weight <500 g (odds ratio, 2.46, 95% confidence interval, 1.96-3.09) were associated with an increased risk of de novo urinary incontinence. A uterine weight >300 g (odds ratio, 1.98, 95% confidence interval, 1.69-2.33), body mass index <25 kg/m(2) (odds ratio, 1.22, 95% confidence interval, 1.01-1.47), prolapse (odds ratio, 2.25, 95% confidence interval, 1.60-3.18), or fibroids (odds ratio, 1.33, 95% confidence interval, 1.09-1.62) as indication for surgery and the absence of daily urge without incontinence preoperatively (odds ratio, 1.51, 95% confidence interval, 1.29-1.76) were associated with an increased remission of urinary incontinence. Vaginal compared with abdominal hysterectomy was associated with a decreased remission of urinary incontinence (odds ratio, 0.70, 95% confidence interval, 0.57-0.87). There was no effect of of age or smoking or a difference between total and subtotal hysterectomy with regard to de novo urinary incontinence or remission of urinary incontinence after the hysterectomy. Residual urinary incontinence and de novo urinary incontinence significantly reduced satisfaction with surgery 1 year postoperatively compared with women without urinary incontinence.

    CONCLUSION: Vaginal delivery, obesity, and daily urge symptoms without incontinence prior to surgery increased de novo urinary incontinence and had a negative influence on the rate of remission of urinary incontinence after hysterectomy, which in turn influenced patients' satisfaction with surgery.

  • 14. Stenström Bohlin, Katja
    et al.
    Ankardal, Maud
    Pedroletti, Corinne
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
    Milsom, Ian
    The influence of the modifiable life-style factors body mass index and smoking on the outcome of mid-urethral sling procedures for female urinary incontinence2015In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 26, no 3, p. 343-351Article in journal (Refereed)
    Abstract [en]

    Introduction and hypothesis: The aim of this observational study was to investigate the influence of body mass index (BMI) smoking and age on the cure rate, rate of complications and patient satisfaction with mid-urethral sling (MUS) procedures.

    Methods: Pre-, peri- and postoperative (8 weeks and 1 year) data were retrieved from the Swedish National Register for Gynecological Surgery of MUS procedures (retropubic procedures, n = 4,539; transobturator procedures, n =1,769) performed between January 2006 and December 2011. Multiple logistic regression analyses were performed between the outcome variables and BMI and smoking, presented as adjusted odds ratios (adjOR) with 95 % confidence interval (CI).

    Results: Subjective 1-year cure rate was 87.4 % for all MUS procedures (88.3 % with the retropubic technique and 85.2 % with the transobturator technique (p = 0.002). Preoperative daily urinary leakage and urgency were more common with increasing BMI, but surgery reduced symptoms in all BMI groups. Lower cure rate was seen in women with a BMI >30 (0.49; CI 0.33–0.73), in diabetics (0.50; CI 0.35–0.74) and women aged > 80 years (0.18; CI 0.06–0.51). Perioperative complications were more common in the retropubic group (4.7 % vs 2.3 % in the transobturator group, p=0.001) and in women with BMI < 25. Smoking did not influence any of the outcome variables.

    Conclusions: The overall 1-year cure rate for MUS procedures was 87 %, but was negatively influenced by BMI >30, diabetes and age > 80 years. Perioperative complications were more common with the retropubic procedure than with the transobturator technique, and in women with a BMI < 25. Smoking did not impact on any of the studied outcome variables.

  • 15. Ståhl, Göran
    et al.
    Broström, Bengt
    Lindkvist, Håkan
    Umeå University, Faculty of Science and Technology, Mathematics and Mathematical Statistics.
    <lindroth, Anders
    Nilsson, Jan
    Olsson, Mats
    Methodological options for quantifying changes in carbon pools in Swedish forests2004In: Studia Forestalia Suecica, ISSN 0039-3150, no 214Article in journal (Refereed)
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