Guidelines to determine the route of hysterectomy

doi:10.1016/0029-7844(94)00318-8

Obstetrics & Gynecology

Volume 85, Issue 1, January 1995, Pages 18-23

https://doi.org/10.1016/0029-7844(94)00318-8 Get rights and content

Objective

To 1) test the validity of a method of assigning patients prospectively to a vaginal, abdominal, or laparoscopy-assisted vaginal approach to hysterectomy for benign disease; 2) compare the outcomes of these options from the day of surgery to the first day of returning to normal activities; and 3) estimate the proportion of hysterectomies by each route when patients were assigned according to this system, and the impact on hospital charges.

Methods

Six hundred seventeen women were assigned to a route of hysterectomy on the basis of uterine size (greater or less than 280 g), presumptive risk factors, and uterine or adnexal immobility or inaccessibility. Data regarding the success of the procedure, complications, length of hospital stay and convalescence, and hospital charges were compiled.

Results

Vaginal hysterectomy alone (n = 548) or in conjunction with laparoscopy (n = 63) was successful in 99.5% of women assigned to these groups. Patients in whom the vaginal route was successful included 94% of those with uterine weights exceeding 280 g and 97% of those having risk factors often cited as reasons for selecting abdominal hysterectomy. Laparoscopic surgery was necessary to permit a transvaginal operation in only 12 of 63 patients (19%). Use of the guidelines produced a potential savings of 615 hospital days, $1,317,434 in hospital charges, and 7250 convalescent days relative to the 3:1 ratio of abdominal to vaginal hysterectomies prevalent in the United States.

Conclusions

Specific guidelines for uterine size, risk factors, and uterine and adnexal mobility and accessibility are useful in selecting the operative approach to hysterectomy and will significantly reduce the number of abdominal operations performed. Laparoscopy is valuable in properly selected patients to determine the route of hysterectomy, but the need for laparoscopic techniques to permit a vaginal operation may be considerably less than some investigators have proposed.

References (18)

WilcoxLS et al.
Hysterectomy in the United States, 1988–1990
Obstet Gynecol
(1994)
SummittRL et al.
Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting
Obstet Gynecol
(1992)
WennbergJE
On patient need, equity, supplier-induced demand, and the need to assess the outcome of common medical practices
Med Care
(1985)
KovacSR et al.
Abdominal versus vaginal hysterectomy: A statistical model for determining physician decision making and patient outcome
Med Decis Making
(1991)
PrecisIV
An update in obstetrics and gynecology
Quality assurance in obstetrics and gynecology
(1989)
FlickingerL et al.
Size and weight determinations of nongravid enlarged uteri
Obstet Gynecol
(1986)
KovacSR et al.
Laparoscopy-assisted vaginal hysterectomy
J Gynecol Surg
(1990)
JohnsonR
Elementary statistics

There are more references available in the full text version of this article.

Cited by (223)

Vaginal Hysterectomy in a Large Health Maintenance Organization: Retrospective Application of a Clinical Algorithm
2021, Journal of Minimally Invasive Gynecology
The primary objective was to describe practice patterns of benign hysterectomy within a large community health maintenance organization (HMO) and evaluate clinical and surgeon characteristics associated with the performance of vaginal hysterectomy (VH). Secondary objectives were to retrospectively apply a VH algorithm to determine how our practice patterns conform, and compare rates of perioperative complications among patients who did and did not meet the algorithm. Patient and surgeon characteristics, and perioperative complications, were compared between patients who underwent VH and did or did not meet the VH algorithm.
Retrospective cohort study.
Large community HMO.
Women undergoing benign hysterectomy.
None.
Route of hysterectomy, patient and surgeon characteristics, perioperative complications. One hundred and thirty-one of 984 (13.3%) benign hysterectomies from January 1, 2013 to June 30, 2015 were vaginal. Patients who were vaginally parous, Hispanic, had normal preoperative uterine size and documentation of uterine descent were more likely to have VH (all p <.05). High-volume surgeons performed 18.8% of their hysterectomies vaginally, as compared to low-volume surgeons who performed 11.4% of their hysterectomies vaginally (p <.01). VH were more likely to be performed by surgeons with longer practice durations than non-vaginal hysterectomies (16.3 vs 12.2 years, p <.01). Seventy-five percent of patients who met the VH algorithm underwent non-vaginal hysterectomy and they had longer operative durations and higher rates of postoperative complications compared to patients who underwent VH. Conversely, patients who underwent VH despite not meeting the VH algorithm did not have significantly different rates of perioperative complications or blood loss than patients who met the VH algorithm.
Seventy-five percent of patients deemed appropriate for VH by our algorithm underwent non-vaginal hysterectomy and had more postoperative complications and longer operative durations. Our data suggest that surgeon characteristics, including surgical volume and duration of practice, may explain some of this performance gap. These findings contribute additional insight into current practice patterns and describe clinical factors that should be included in VH algorithms.
Surgical outcomes of hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) compared with laparoscopic total hysterectomy (LTH) in women with non-prolapsed and benign uterine diseases
2020, Taiwanese Journal of Obstetrics and Gynecology
We aimed to compare the surgical outcomes between hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and laparoscopic total hysterectomy (LTH).
This study is a retrospective chart analysis. From January 1, 2015, to December 31, 2017, a total of 183 patients of reproductive age with an indication for hysterectomy due to non-prolapsed and benign uterine diseases were enrolled. After exclusion, 20 patients were included in the vNOTES group, and 66 patients were included in the LTH group. Various post-operative surgical outcomes such as operative time, blood loss, uterus weight, a decrease in hemoglobin level on post-operative day one, post-operative pain scale, complications, length of hospitalization, and re-admission rate were measured.
No difference was observed between both groups regarding operative time, blood loss, uterine weight, a decrease in hemoglobin level on post-operative day one, complications, hospital stay, and re-admission rate. Patients in the vNOTES group had significantly less post-operative pain compared with those in the LTH group (p = 0.03).
The surgical outcomes of hysterectomy by vNOTES could be similar to those of LTH. Patients undergoing hysterectomy by vNOTES may have less post-operative pain compared with those undergoing LTH. However, the sample size was small, and the results need more evidence to confirm these findings.
Vaginal vs. robotic hysterectomy for patients with endometrial cancer: A comparison of outcomes and cost of care
2017, Gynecologic Oncology
To compare outcomes and cost for patients with endometrial cancer undergoing vaginal hysterectomy (VH) or robotic hysterectomy (RH), with or without lymphadenectomy (LND).
Patients undergoing planned VH (and laparoscopic LND) or RH (and robotic LND) between January 2007 and November 2012 were reviewed. Patients with stage IV disease, synchronous cancer, synchronous surgery, or treated with palliative intent were excluded. Patients were objectively triaged to LND per institutional protocol based on frozen section. Outcomes were compared between VH and RH groups matched 1:1 on propensity scores.
VH was planned in 153 patients; 60 (39%) had concurrent LND while 93 (61%) were low risk and did not require LND. RH was planned in 398 patients; 225 (56%) required concurrent LND and 173 (44%) did not. Among 50 PS-matched pairs without LND, there was no significant difference in complications, length of stay, readmission, or progression free survival. However, median operative time was 1.3 h longer and median 30-day cost $3150 higher for RH compared to VH (both p < 0.001).
Among patients requiring LND, 42 PS-matched pairs were identified. Median operative time was not different when pelvic and para-aortic LND was performed, and 12 min longer in the VH group for pelvic LND alone (p = 0.03). Median 30-day cost was $921 higher for RH compared to VH when LND was required (p = 0.08).
Utilization of vaginal hysterectomy for endometrial cancer results in similar surgical and oncologic outcomes and lower costs compared to RH and should be considered for appropriate patients with a low risk of requiring LND.
A Favorability Score for Vaginal Hysterectomy in a Statewide Collaborative
2016, Journal of Minimally Invasive Gynecology
Because it is associated with fewer complications and more rapid recovery, the vaginal approach is preferred for benign hysterectomy. Patient characteristics that traditionally favor a vaginal approach include adequate vaginal access, small uterine size, and low suspicion for extrauterine disease. However, the low proportion of hysterectomies performed vaginally in the United States suggests that these data are not routinely applied in clinical practice. We sought to analyze the association of parity, prior pelvic surgery, and uterine weight with the use of the vaginal, laparoscopic, robotic, and abdominal approaches to hysterectomy.
A retrospective cohort study (Canadian Task Force classification II-2).
The Michigan Surgical Quality Collaborative is a statewide organization of 52 academic and community hospitals in Michigan funded by Blue Cross and Blue Shield of Michigan/Blue Care Network, including patients from all insurance payers.
Five thousand six hundred eight women undergoing hysterectomy for benign gynecologic conditions from January 1, 2013, through December 8, 2013, and included in the Michigan Surgical Quality Collaborative.
To assess potential for vaginal hysterectomy, a favorability score of 0, 1, 2, or 3 was calculated by summing 1 point each for parity ≥1, no prior pelvic surgery, and uterine weight <250 g. Frequencies of surgical approaches to hysterectomy were compared using chi-square tests across favorability scores.
The use of robotic hysterectomy was most frequent (41.9%, n = 2349/5608) followed by abdominal (19.7%, n = 1103/5608), laparoscopic (14.4%, n = 809/5608), vaginal (13.5%, n = 758/5608), and laparoscopic-assisted vaginal (10.5%, n = 589/5608) hysterectomy. With favorability scores of 0, 1, 2, and 3, vaginal hysterectomy was performed in 0.6% (n = 1/167), 5% (n = 66/1324), 13.7% (n = 415/3036), and 25.5% (n = 276/1081) of cases and abdominal hysterectomy in 41.9% (n = 70/167), 30.8% (n = 408/1324), 17.5% (n = 531/3036), and 8.7% (n = 94/1081), respectively. There was little variation in the rates of laparoscopic hysterectomy (13.3%–16.8%, p = .429) and robotic hysterectomy (39.5%–42.4%, p = .518) across favorability scores.
In a population of women undergoing hysterectomy in the state of Michigan, the use of vaginal and abdominal hysterectomy varied with respect to parity, prior pelvic surgery, and uterine weight, but there was little variation in the use of laparoscopic and robotic approaches. The favorability score could potentially be used as a quality improvement tool to evaluate practice patterns with respect to the use of various surgical approaches to hysterectomy.
Surgical site infection after hysterectomy
2013, American Journal of Obstetrics and Gynecology
Our objective was to estimate the occurrence of surgical site infections (SSI) after hysterectomy and the associated risk factors.
We conducted a cross-sectional analysis of the 2005-2009 American College of Surgeons National Surgical Quality Improvement Program participant use data files to analyze hysterectomies. Different routes of hysterectomy were compared. The primary outcome was to identify the occurrence of 30-day superficial SSI (cellulitis) after hysterectomy. Secondary outcomes were the occurrence of deep and organ-space SSI after hysterectomy. Logistic regression models were conducted to further explore the associations of risks factors with SSI after hysterectomy.
A total of 13,822 women were included in our final analysis. The occurrence of postoperative cellulitis after hysterectomy was 1.6% (n = 221 women). Risk factors that were associated with cellulitis were route of hysterectomy with an adjusted odds ratio (AOR) of 3.74 (95% confidence interval [CI], 2.26–6.22) for laparotomy compared with the vaginal approach, operative time >75th percentile (AOR, 1.84; 95% CI, 1.40–2.44), American Society of Anesthesia class ≥ 3 (AOR, 1.79; 95% CI, 1.31–2.43), body mass index ≥40 kg/m² (AOR, 2.65; 95% CI, 1.85–3.80), and diabetes mellitus (AOR, 1.54; 95% CI, 1.06–2.24) The occurrence of deep and organ-space SSI was 1.1% (n = 154 women) after hysterectomy.
Our finding of the decreased occurrence of superficial SSI after the vaginal approach for hysterectomy reaffirms the role for vaginal hysterectomy as the route of choice for hysterectomy.
Does medical debulking with gonadotrophin-releasing hormone agonist facilitate vaginal hysterectomy with a moderate enlarged uterus? A randomized control study
2013, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
While laparoscopy is a useful adjunct to VH when extensive adhesiolysis is contemplated or when there is suspected adnexal pathology, we concur with previous authors [13,29–31] that laparoscopic assistance is not otherwise necessary for the vaginal removal of a moderately enlarged uterus. The mean weight of uteri removed in the present study was high, above the limit of 280 g (12 weeks’ gestation) that was recommended as the limit for vaginal hysterectomy [22,23]. In most cases the uterine weight was at least 500 g, with no special difficulties.
Vaginal hysterectomy is considered the method of choice for removal of the uterus but most gynecologists still prefer the abdominal route for removal of benign uteri >14 weeks in size. Conversion of an abdominal to a potential vaginal hysterectomy by uterine size reduction would be advantageous. Gonadotrophin-releasing hormone (GnRH) agonists can reduce uterine bulk by up to 50%.
To evaluate the efficacy of the preoperative administration of a GnRH agonist for women with enlarged non-prolapsing uteri in order to facilitate vaginal hysterectomy, in comparison with patients with enlarged uteri who underwent direct total abdominal hysterectomy (TAH) for the same indication (menorrhagia).
Randomized controlled study. Women scheduled for hysterectomy for menorrhagia with a non-prolapsing uterus of ≥14 weeks size (by clinical and sonographic assessments) were offered a trial of vaginal hysterectomy after pre-treatment with a GnRH agonist (goserelin) for 3 months (study group = Group 1 = 40). A group of women with uteri of comparable size who underwent abdominal hysterectomy for similar indications served as controls (Group 2 = 40). Pre- and post-operative data such as hemoglobin, myoma size, uterine weight, duration of procedure and complications, pain score and length of hospital stay were collected prospectively.
The weight of the uterine specimen was significantly lower in Group 1 (511.7 ± 217 g) compared to Group 2 (736.8 ± 212 g); P < 0.001. The mean objective decrease in clinical uterine bulk preoperatively in Group 1 was 20.1%. The duration of surgery was nearly 1.5 times as long in vaginal (119.6 ± 41.7 min) compared to abdominal hysterectomy (81.1 ± 34.1 min), P < 0.001, but analgesia use and the length of inpatient stay were significantly lower in Group 1 (2.6 ± 1.3 days) compared to Group 2 (4.12 ± 1.7 days), P < 0.001. There was no significant difference between the two groups as regards the rate of occurrence of surgical complications.
In women with ≥14 week size uteri, treatment with a GnRH agonist reduces uterine size sufficiently to allow safe vaginal hysterectomy. Although duration of surgery was longer, women who underwent vaginal hysterectomy required less analgesia and had a shorter inpatient stay.

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View full text

Guidelines to determine the route of hysterectomy

Objective

Methods

Results

Conclusions

Hysterectomy in the United States, 1988–1990

Obstet Gynecol

Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting

Obstet Gynecol

On patient need, equity, supplier-induced demand, and the need to assess the outcome of common medical practices

Med Care

Abdominal versus vaginal hysterectomy: A statistical model for determining physician decision making and patient outcome

Med Decis Making

An update in obstetrics and gynecology

Quality assurance in obstetrics and gynecology

Size and weight determinations of nongravid enlarged uteri

Obstet Gynecol

Laparoscopy-assisted vaginal hysterectomy

J Gynecol Surg

Elementary statistics