Hysterectomy Fact versus fiction Richard Dover Specialist Gynaecologist
Disclaimer
Disclaimer
Hysterectomy An update? Myths busted?
HYSTERECTOMY Retro-chic!
HMB Important cause of morbidity Affects 1:5 women Medical treatment. Long-term. Poor compliance and treatment failure. Mirena Ablation Hysterectomy = 100% amenorrhoea
Mirena 80-90% reduction in MBL Amenorrhoea in 20-30% of users 36% decrease in hysterectomies in the UK between 1990-2000. Mirena effect??
However Some data.. Over 5 years, up to 50% of women using the Mirena IUS for menorrhagia will undergo hysterectomy.
And also Comparing hysterectomy to LNG-IUS with regard to sexual function Sexual satisfaction increased and sexual problems decreased with hysterectomy
Whereas sexual satisfaction with the partner was reduced among women using the LNG-IUS.
HYSTERECTOMY
700,000 pa in the US Incidence
589,999 per year Benign disease
49,166 per month 11346 per week 1616 per day 67 per hour 1 per minute
USA 1/3 of all women by age 60
Incidence falling by 1% per year in the developed world?
Not only does the overall hysterectomy rate vary, so does the percentage performed by each route. Varies between Countries Within countries Within the same unit
VALUE 1995 (UK) 67% of hysterectomies were abdominal
USA 2003 602,457 hysterectomies 538,722 for benign disease 66% abdominal 22% vaginal 12% laparoscopic
USA 2003 Route % Age Stay Abdominal 66 44.5 3 Vaginal 22 48.2 2 Laparoscopic 12 43.6 1.7
Type of hysterectomy. The OWH experience Audit of operative lists in 2013 Christchurch and SX Invercargill All clinicians (except MGL oncology cases)
TLH LAVH VH TAH 98 92 5 9 Total number of hysterectomies 204 Open hysterectomy rate 4.4%
Hysterectomy at OWH 95% laparoscopic/vaginal procedures Hospital stay of 1-2 nights Driving 10 days Back to work / activities 4 weeks
But which type of hysterectomy? The safest in the hands of the surgeon concerned. Long-term, little difference in outcome
Types of hysterectomy Abdominal Can be total or subtotal Vaginal Laparoscopic
Laparoscopic LAVH or TLH Relates to the route of division of the uterine arteries
Laparoscopic Visualisation of the pelvis Concomitant pathology (endometriosis) Removal of tubes and ovaries
Abdominal Total includes removal of cervix Sub-total. Cervix retained
Sub-total hysterectomy Why? Surgeon benefits. Patient benefits.
Surgeon benefits Removal of the cervix is usually the most difficult part of the procedure Deep pelvis Adherent bladder (multiple C/sections) Risk of injury to bladder and ureter
Patient benefits Avoidance of surgical risks Improvement with regard to function of pelvic floor (why?) Bladder/bowel/sexual
Sub-total Vs Total Sub-total (%) Total (%) Urinary frequency pre-op 33 31 Postop @ 12/12 24 20 Nocturia/bladder capacity/bowel problems/sexual function = NO DIFFERENCE
The reality. TAH Vs SAH Complications Symptom relief Sexual function Bowel and bladder function NO DIFFERENCE
Sub-total. The drawbacks. Cervical screening Discharge/bleeding (how to avoid) HRT
Assuming safety is equal. The least invasive technique should be used. We should be moving away from abdominal surgery to vaginal and laparoscopic surgery. Long-standing, perceived contra-indications are unproven. Previous C/section No vaginal births/no uterine descent
Previous C/section Some evidence to suggest that a vaginal procedure is safer than an abdominal one The dissection starts in the previously undamaged portion of the tissue plane
Vaginal Vs Abdominal VH is associated with Quicker return to daily activities (MD 9/7) Fewer febrile episodes (OR 0.42) Shorter duration of hospital stay (MD 1.1/7)
Laparoscopic Vs Abdominal The benefits of a VH BUT Associated with Increased urinary tract injuries (OR 2.4) Increased operating time (MD 20.3 minutes)
But This data is from large studies with many differing operators. How do we interpret this Scandanavian study?
Makinen 2001 Prospective study looking at the learning curve of hysterectomies. Injuries to adjacent organs were strongly associated with the experience of the operating surgeon.
Brummer 2008 VH rate in Finland in 1980 s = 7% Meetings and mentoring in vaginal and laparoscopic surgery were then instituted. VH rate in 2004 = 39% BUT during this time the rate of ureteric injuries decreased.
Incidence Largely historical data Incidence changing? Type of hysterectomy changing?
TLH LAVH VH TAH 98 92 5 9 Total number of hysterectomies 204 Open hysterectomy rate 4.4% A willingness to try a vaginal or laparoscopic procedure. Surgical mindset. TLH/LAVH becomes the default
Hysterectomy. Outcomes Symptom severity/depression/anxiety. All decrease significantly. QOL increases significantly But ~8% have as many problems postoperatively Related to pre-existing emotional/psychological problems, depression and low income
Hysterectomy. Satisfaction.
Satisfaction 12 months 24 months Symptoms completely resolved 96% 96% Outcome better than expected 93% 94% Health better 85% 82%
Psychological outcome Previous studies retrospective Most showed an adverse outcome with mood In all prospective studies, mood improves with relief of distressing gynaecological symptoms
Sexual functioning Pre-op (%) 12/12 post-op (%) Having sex 70.5 77 Frequency of dyspareunia 18.6 4 Anorgasmia 7.6 5 Low libido 10.4 6
Sexual functioning Pre-hysterectomy depression is associated with post-operative dyspareunia, dryness, reduced libido and anorgasmia.
Urinary and sexual function Prospective study. Reduced incidence of stress incontinence, urgency and deep dyspareunia postoperatively. Irrespective of type of hysterectomy
Urinary symptoms Compared outcomes between VH and balloon ablation Urge and UI the same in each group.
Ovarian failure Complex issue of HRT The post-menopausal ovary remains an important source of testosterone production A greater % of surgically menopausal women have low sexual desire compared to premenopausal or naturally menopausal women
Ovarian failure Siddell et al 1987 Age at menopause TAH (ovaries conserved) 45.4 +/- 4 Matched controls 49.5 +/- 4.1
Ovarian failure NZ data TAH = menopause ~ 4 years earlier
Risk of prolapse US longitudinal study 162,000 women 470,000 matched controls 1973-2003 3.2% of hysterectomy patients had POP surgery compared to 2% of controls
Prolapse Hazard ratio (HR) 1.7 overall BUT HR 3.8 if had VH HR Hysterectomy- no births 1 Hysterectomy 1 vaginal birth 2 Hysterectomy 4 vaginal births 11.3
The role of salpingectomy 2001: recognition of significant dysplasia in the distal fallopian tube of BRCA1/2 carriers undergoing preventive BSO Further studies have noted in-situ serous tubal carcinomas in 60-100% of BSO specimens from BRCA1/2 patients But also in 30-60% of specimens from women with high-grade serous carcinomas who do not carry the mutations
The numbers Risk of ovarian cancer by age 50 is ~ 1 : 335 Rises to 1 : 65 between ages 50 70 Suggestion that bilateral salpingectomy reduces the risk of ovarian cancer by 40% ~ 100 bilateral salpingectomies need to be performed to prevent one case of ovarian cancer
Change in practice Canada 2006 11 Bilateral salpingectomies, at the time of hysterectomy, increased from 1% to 11% during this period Highest rate, 38.5% seen in British Columbia
Conclusion HMB bleeding is a common complaint There are many treatment options available Some come into, and then go out of favour Hysterectomy-ablation-Mirena..hysterectomy?
Hysterectomy Have we come full circle? There are undoubted long-term benefits to this operation (the pros). With the advances in surgical techniques, the drawbacks have been altered (the cons) Is reappraisal required??