COMPARATION AMONG THE MAIN HYSTERECTOMY ROUTES Olsen, PR (Medical Student, UFRGS, Porto Alegre, Brazil); Souza, CAB (PhD HCPA, Porto Alegre, Brazil); Chapon, R (Post Graduate Student, UFRGS, Porto Alegre, Brazil); Passos, MP (Medical Student, UFRGS, Porto Alegre, Brazil); Goidanich, MC (Medical Student, UFRGS, Porto Alegre, Brazil); Genro, V (PhD, HCPA, Porto Alegre, Brazil); CunhaFilho, JS ( Professor of Medicine, UFRGS, Porto Alegre, Brazil);
Introduction Hysterectomy is one of the most common surgical procedures made for gynecological benign diseases. In Brazil, on 2014, 106.627 hysterectomies were performed There are many surgical approaches for the hysterectomy and the studies diverge on choosing the best surgical approach that is more effective, that has less post-operatory complications and that brings best life-quality after the procedure
General Consensus: Vaginal Route > Laparoscopic Route > Abdominal Route Even though, there is no general agreement due to the lack of well-designed studies with enough sample sizes for external validation.
Materials and Methods In a retrospective cohort study, we reviewed the medical records from 195 women who underwent hysterectomy from 2009 to 2013 in Hospital de Clínicas de Porto Alegre. They were divided in three groups as the chosen route of surgery: videolaparoscopy (135), abdominal (36) and vaginal (21). We excluded from the study women when the surgery was due uterovaginal prolapse (54 patients) and genital prolapse (21 patients)
Materials and Methods Postoperative complications were classified as: minor complications (that included headache, nausea, vomit, dysuria, subcutaneous hematoma, urinary retention, vaginal bleeding, fever, candidiasis, abdominal distention, pain, urinary tract infection, vaginosis and seroma) major complications (that included urgency reintervention, ureteral obstruction, debridement of wound dehiscence and removal of pyogenic granuloma) All the data collection was made through medical records review and missing data were not replaced. Data were transcribed to Excel 2013 and analyzed by SPSS 22 program.
Materials and Methods For nominal variables, the χ 2 test was used and, for quantitative variables, the ANOVA test was performed. Multivariate logistic regression analysis was used for the significant variables when necessary. Statistical significance was set at P <0.05
Results
Videolaparoscop Abdomina Vaginal P y l Age (years±sd) 44.5±5.33 45±4.92 49.5±7.86 0.02 Irregular Cicles (%) 71.1 61.7 66.7 0.318 Chronic Pelvic Pain (%) 37.9 24.2 23.8 0.09 Dyspareunia (%) 36.9 21.2 19.1 0.086 Dysmenorrhea (%) 52% 26% 57% 0.019 Regular Pap Test (%) 81% 80% 90% 0.254 Menarche (years) 12.8±1.8 12.4±1.53 12.8±2.01 0.75 Surgical indication 0.104 Excessive and frequent menstruation with irregular cycle 13.4 5.5 19.1 Uterine leiomyoma 18.2 36.1 23.8 Excessive vaginal bleeding in 21.2 16.7 4.7 premenopausal Abnormal bleeding from the uterus or vagina, unspecified 28.5 22.2 28.6
The average uterine weight in the abdominal group was heavier in the abdominal group (542.6±404.1) than the vaginal group (199.9±72.5, p=0.00) and heavier than the videolaparoscopy group (209.4±168.4, p=0.00) There were no other statistical differences
Videolaparoscopy took a longer time than the surgeries by the vaginal route (p=0.024). There were no other statistical differences
Abdominal group took the longest hospital stay (3.62±1.8 days), against the laparoscopy group (2.66±1.0 days, p=0.017) and the vaginal group (2.62±0.5 days, p<0.001) There were no other statistical differences
Codein was more prescribed to patients in the abdominal group(p=0.012) There were no other statistical differences
There was no statistically significant difference among the groups about medical prescription of common painkillers, nonsteroidal anti-inflamatory, antispasmodic and morphine
There were no statistical differences
There were no statistical differences Urinary tract infection was a frequent minor complication in the Vaginal Group!
Graph about the pain complaints in the medical interview after the surgery In the second postoperative., the women in the videolaparascopy group reported more pain than the patients in the vaginal group (44.3% vs 11.8%, p=0,004) There were no other statistical differences
Conclusion Operative Time Duration of Hospital Stay Medical Prescription of Codein Medical Prescription of other painkillers Complications after the surgery Pain complaint in the postoperative medical interview Laparoscopic Abdominal Vaginal longest longest Most prescribed = = = = =? Most complaints (reliable significance)
Conclusion There are no major differences among the surgical approaches However, in agreement with other studies, we believe that the vaginal approach should be the first method of choice when possible because of its probable lower morbidity. A study comparing historical data might be necessary A Randomized Controlled Trial would be the best research design, however hysterectomy is a surgical procedure and it s difficult to control the clinical features and to randomize the patients
Acknowledgement Infertility and endometriosis research team in Hospital de Clínicas de Porto Alegre João Sabino Cunha-Filho