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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Basildon & Thurrock General Hospitals, Basildon, UK, and the Department of Obstetrics and Gynecology, Royal Free and University College London Medical School, London, UK.
Address reprint requests to: Rajiv Varma, MRCOG Basildon Hospital Consultant Gynecologist Nether Mayne Basildon Essex, SS16 5NL United Kingdom E-mail: rvarma80{at}hotmail.com
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Abstract |
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Methods: Practice over 5 years at a district general hospital in the United Kingdom was studied. Patients with prolapse, adnexal disease, leiomyoma larger than 16 weeks, and malignancy were excluded, leaving 272 hysterectomies of 553 originally. Change in the route of hysterectomy, the main endpoint, was observed at yearly intervals.
Results: At the start of the study, the route of surgery was 68% abdominal and 32% vaginal. By the end of the fifth year the pattern was 5% abdominal 95% vaginal. The conversion from vaginal to abdominal hysterectomy occurred in only two cases during the study period. There was no change in the case mix during this period. In the fifth year of study most associated oophorectomies were also performed vaginally. There was no increase in patient morbidity.
Conclusion: A major determinant of the route of hysterectomy is not the clinical situation but the attitude of the surgeon. There is no need for extra training and special skills or complicated equipment for vaginal hysterectomy.
Despite improvements in medical therapy for menstrual disorders and the development of minimal access surgical techniques for endometrial ablation, the number of hysterectomies has not diminished significantly in the United Kingdom. According to the Royal College of Obstetricians and Gynecologists, 62,775 hysterectomies were done in England and Wales in 1998. Currently, abdominal hysterectomy exceeds vaginal hysterectomy by a ratio of 4:1 for the treatment of benign disease, whereas the vaginal route is mainly restricted to the treatment of prolapse.1,2
Ideally, the reverse should be the case: the vaginal route for hysterectomy has fewer perioperative complications and allows earlier recovery and return to work.3,4 Vaginal hysterectomy is also less expensive than either abdominal or laparoscopically assisted hysterectomy. A recent study found that the cost of abdominal and laparoscopically assisted vaginal hysterectomies were 34.5% and 72% higher than for vaginal hysterectomies, respectively.5 Therefore, significant reductions in health care costs could be possible if the vaginal route predominated.
Despite strong advocacy for the vaginal approach and guidelines to determine the route of hysterectomy, change in practice has not occurred.1,6,7 The Royal College of Obstetricians and Gynaecologists recently recommended that the mode of hysterectomy should be audited to determine the optimum rate of vaginal hysterectomy.8 Explanations offered for the lack of change include surgeon preference, no uterine descent, and a need for more training in vaginal surgery.5,7 Vaginal hysterectomy (for prolapse) is part of the repertoire of every trained gynecologist. It is therefore likely that attitude rather than aptitude is the issue affecting the choice of route used.
This study investigates one approach to change the existing practice. We report the outcome when an average practicing gynecologist with no extra training followed a deliberate decision to carry out all hysterectomies vaginally if technically possible.
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Materials and Methods |
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AbstractMaterials and MethodsResultsDiscussionReferences |
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We recorded age, parity, weight, previous surgical history, indication for hysterectomy, need for oophorectomy, and postoperative fall in hemoglobin level. Each operation was classified as difficult (leading to change of route intraoperatively) or normal. Complications were classified as intraoperative, immediate postoperative (within 6 weeks), and late postoperative (after 6 weeks). Postoperative pyrexia was defined as temperature of more than 38C on two or more occasions, excluding the first 24 hours after the operation.
According to our unit policy, each patient received one intravenous dose of a prophylactic antibiotic agent during the surgical procedure and low molecular weight subcutaneous heparin prophylaxis against thromboembolism (first dose with the premedication and a daily dose on the first and second day after operation). In all other respects, management was standard during the period of study.
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Results |
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. In our series, 201 of 273 operations (74%) were for some form of menstrual dysfunction in the absence of major pelvic disease.
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shows the distribution of abdominal and vaginal hysterectomies performed per year from 1994 to 1998. The proportion achieved vaginally rose steeply from 32% in 1994 to 95% in 1998. There was also a steep rise in the vaginal removal of ovaries from none in the first year of study to an oophorectomy rate of 88% in the final year (Table 4).
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Discussion |
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The lack of training in vaginal surgery can no longer be used as a valid reason for not removing at least normal-sized uteri vaginally. The learning curve is very short as shown by this study, the complications were few, and the rate reached from 32% to 95% within a short period of time. The changeover to abdominal route is rare and as the surgeon’s experience grows he or she is able to handle more difficult cases, as shown by the increase in the proportion of vaginal oophorectomies in our study. All other contraindications to vaginal hysterectomy, such as vaginal narrowing, inaccessibility of the uterus, and lack of uterine descent, lose their importance with increasing experience. Nulliparity and previous cesarean delivery are also not contraindications to safe and technically straightforward vaginal removal of the uterus or more specifically for evaluating its practicality under anesthesia. In our experience removing the nulliparous uterus vaginally is often easier than expected because of the small size of the cervix and the uterus.
In our view, the surgeon should offer the option of vaginal hysterectomy to all patients with benign disease with the proviso that it may be necessary to convert to an abdominal operation if unexpected problems occur. This stance also is recommended when patients consent to laparoscopically assisted vaginal hysterectomy and is rational and ethical. Our approach was extremely cautious but open-minded and focused mainly on making the decision regarding the route of hysterectomy with the patient in the surgical theater under anesthetic, after appropriate counseling. The overall low rate of complications demonstrates that this approach was reasonably safe. More important was the lack of complications during the initial phase of the study (the learning curve used to explain high complication rates when new techniques are introduced).
This simple change in practice and attitude advocated by Sheth6 led to the experience reported here. Our observations are in agreement with the findings of a recent large study by Kovac5 that provides compelling evidence in favor of vaginal hysterectomy as the route of choice for benign uterine diseases. A wealth of data are available on the feasibility of removing a nonprolapsed uterus vaginally6,9 and of the superiority of the vaginal route of hysterectomy.1,3,5–8,10–13 Lower hospital costs follow from the shorter patient stay.4,7,13–15 Because hysterectomy is the most common gynecologic operation, any potential savings associated with the use of the vaginal route could have a remarkable effect on the cost of gynecologic surgery.
A shorter length of stay is a desirable outcome from both the patient’s and the hospital’s perspective. This study did not look at the length of stay and return to work cost–benefit analysis but patients having vaginal hysterectomy reported returning to normal activity levels sooner and had more favorable quality of life scores than patients who had abdominal hysterectomy or laparoscopically assisted vaginal hysterectomy.16
We acknowledge the occasional role of laparoscopy. We used it as a tool for excluding coexisting pathology such as severe endometriosis or postoperatively to rule out hemorrhage in a handful of cases. Enthusiasts promote laparoscopically assisted vaginal hysterectomy as a technique to convert an abdominal hysterectomy into a vaginal hysterectomy.17 This technique requires a high level of laparoscopic skills, expensive equipment, and longer operating time. The approach recommended here has none of those disadvantages. Our study clearly shows that the laparoscope is not essential to facilitate a vaginal hysterectomy. It should be used only in a small number of properly selected patients with a suspicion of coexisting pathology.
How should a switch from planned vaginal to an abdominal route occur safely and expeditiously? Patient safety demands that when this point occurs during the operation it should be recognized promptly without any feeling of failure. For those beginning this approach we would recommend that when there is apparent difficulty in the vaginal approach and no progress is being made, the surgeon should ask the scrub nurse to note the time. Thereafter a maximum of 10–15 more minutes should elapse before opening the abdomen. This situation proved a rare event even in the early parts of the study.
We have established that all patients requiring a hysterectomy for menstrual problems with a moderate-sized uterus can be offered the vaginal route of surgery with appropriate counselling. This group comprises most of the women undergoing hysterectomies in our practice and, we believe, across the western world. All that is required for this change is the willingness of the surgeon to alter practice. If implemented this pattern of practice would reduce surgical costs significantly. The safety record we have demonstrated and the practical success of this approach suggests that all surgeons should be prepared to investigate this policy shift. It follows that patient groups and health care providers should be asking those surgeons who do not, why they fail to do so.
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Footnotes |
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Received July 31, 2000. Received in revised form November 19, 2000. Accepted December 15, 2000.
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References |
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2. Mulholland C, Harding N, Bradley S, Stevenson M. Regional variation in the utilization rate of vaginal and abdominal hysterectomies in the United Kingdom. J Public Health Med 1996;18: 400–5.
3. Dorsey JH, Holtz PM, Griffiths RI, McGrath MM, Steinberg EP. Cost and changes associated with three alternative techniques of hysterectomy. N Engl J Med 1996;335:476–82.
4. Kovac SR, Christie SJ, Bindbeutel GA. Abdominal versus vaginal hysterectomy, a statistical model for determining physician’s decision making and patient outcome. Med Decis Making 1991;11: 19–28.
5. Kovac SR. Hysterectomy outcomes in patients with similar indications. Obstet Gynecol 2000;95:787–93.
6. Sheth SS. Vaginal hysterectomy. In: Studd J, ed. Progress in obstetrics & gynecology. vol 10. Edinburgh, UK: Churchill Livingstone, 1993:317–39.
7. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet Gynecol 1995;85:18–23.[Abstract]
8. Royal College of Obstetricians and Gynecologists. Effective procedures in gynaecology suitable for audit. London: Royal College of Obstetricians and Gynaecologists, 1998.
9. Unger JB. Vaginal removal of the benign non-prolapsed uterus: Experience with 300 consecutive operations. Am J Obstet Gynecol 1999;180:1337–44.[Medline]
10. Pratt JH, Daikoku NH. Obesity and vaginal hysterectomy. J Reprod Med 1990;35:944–5.
11. Gitch G, Berger E, Tatra G. Trends in thirty years of vaginal hysterectomy. Surg Gynecol Obstet 1991;172:207–10.[Medline]
12. Carlson KJ. Outcomes of hysterectomy. Clin Obstet Gynecol 1997; 40:939–49.[Medline]
13. Ransom SB, Mc Neeley SG, Whight C, Diamond MP. A cost analysis of endometrial ablation, abdominal hysterectomy, vaginal hysterectomy and LAVH in the treatment of primary menorrhhagia. J Am Assoc Gynecol Laparosc 1996;4:29–32.[Medline]
14. Van den Eeden SK, Glasser M, Mathias SD, Colwell HH, Pasta DJ, Kunz K. Quality of life, healthcare utilization and costs among women undergoing hysterectomy in a managed care setting. Am J Obstet Gynecol 1998;178:91–100.[Medline]
15. Nezhat C, Bess O, Admon D, Nezhat CH, Nezhat F. Hospital cost comparison between abdominal, vaginal and laparoscopy assisted vaginal hysterectomies. Obstet Gynecol 1994;83:713–6.[Medline]
16. Summitt RL, Stovall TG, Lipscomb GH, Ling FW. Randomised comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol 1992;80:895–901.
17. Langebrekke A, Eraker R, Nesheim BI, Urnes A, Busund B, Sponland G. Abdominal hysterectomy should not be considered as a primary method for uterine removal. A prospective randomised study of 100 patients referred to hysterectomy. Acta Obstet Gynecol Scand 1996;75:404–7.[Medline]
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