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 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 321-324

Hysterectomy: Rates and routes controversies


Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Navi Mumbai, Maharashtra, India

Date of Submission10-Nov-2021
Date of Acceptance10-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Sushil Kumar
Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Navi Mumbai 410209, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_92_21

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How to cite this article:
Kumar S, Vijan T. Hysterectomy: Rates and routes controversies. MGM J Med Sci 2021;8:321-4

How to cite this URL:
Kumar S, Vijan T. Hysterectomy: Rates and routes controversies. MGM J Med Sci [serial online] 2021 [cited 2022 Jan 18];8:321-4. Available from: http://www.mgmjms.com/text.asp?2021/8/4/321/333334



Hysterectomy is one of the most frequently performed gynecological procedures between the age group of 44 and 54 years of age, for benign gynecological diseases, most commonly abnormal uterine bleeding, prolapse, and uterine fibroids.[1] It involves the removal of the uterine corpus with or without the cervix to cure several gynecological complaints. It also has its share of controversies too, both about the “Rates and Routes.” Social activists often raise the issues of medically unnecessary hysterectomies being performed by gynecologists for monetary gains. Even in terms of “Routes of hysterectomy” or method of hysterectomy, there is no consensus. At times, two gynecologists may not agree on the route of hysterectomy suitable for a particular patient.

Traditionally, hysterectomy was performed using either an abdominal or vaginal approach. More recently, laparoscopic techniques have been used.[2] Total vaginal hysterectomy (TVH) involves removal of the uterus via the vagina, without an abdominal incision. An abdominal hysterectomy involves the removal of the uterus through an incision in the lower abdomen. Laparoscopic hysterectomy (LH) involves “keyhole surgery” through small incisions in the abdomen.[1] The selection of the route of hysterectomy for benign causes can be influenced by many factors such as the size and shape of the uterus; accessibility to the uterus; extent of extra-uterine disease; the need for concurrent procedures; surgeon’s training and experience; whether the case is emergent or scheduled; and the preference of a well-informed patient.[3]


  History Top


The operation was first described in the third-century AD by Soranus and before the turn of this century carried a very high surgical morbidity and mortality rate.[4] The origins of planned vaginal and abdominal hysterectomy are traced from the nineteenth century after the pioneering work of Sutton.[5] The plaudit for the first abdominal hysterectomy with a survivor is all American and goes to Walter Burnham, who operated in Lowell, Massachusetts, in 1853.[6] Later that year, in September, in the same town of Lowell, Gilman Kimball performed the first deliberate hysterectomy because of a fibroid tumor, and the patient survived the operation.[7] With the technological advances made during this century in both medical and surgical specialties, the operation has become quite safe.[4] Advances in anesthesia, blood transfusion, antibiotics, and surgical technique led to hysterectomy becoming the second most common operation in women.[5]


  Rates of hysterectomy in india Top


A multivariate study performed in 2019 states that in India, the prevalence of hysterectomy operation was 3.2%, the highest in Andhra Pradesh (8.9%), and the lowest in Assam (0.9%). Rural India had a higher prevalence than urban India. The majority of women underwent the operation in private hospitals. Hysterectomy prevalence ranged between 3% and 5% in 126 districts, 5% and 7% in 47 districts, and >7% in 26 districts. Age, parity, wealth, and insurance were positively associated with the prevalence of hysterectomy, whereas education and sterilization were negatively associated.[8]

Another meta-analysis study at the national level states that there were higher odds of hysterectomy in women with higher age, parity, and those residing in rural areas. Evidence indicated that women with at least 5–10 years of education had lower odds of reporting hysterectomy as compared with women without formal schooling.[9]


  Rates of hysterectomies in other countries Top


United States

Estimates suggest that one in nine women will undergo hysterectomy during their lifetime and that approximately 6,00,000 procedures are performed each year in the United States.[10]

Europe

Approximately 55,000 hysterectomy operations are carried out in the UK each year. The age-standardized incidence per 1,00,000 women ranges from 173/1,00,000 women in Denmark to 295/1,00,000 in Germany.


  Routes of hysterectomy Top


Abdominal hysterectomy

It has traditionally been the surgical approach for gynecological malignancy or when another pelvic pathology is present such as endometriosis or adhesions or in the context of a very large uterus. It remains the “fallback option” if the uterus cannot be removed by any other approach. Mini-abdominal hysterectomy refers to an approach where the abdominal incision does not exceed 7 cm.[1] The rates of abdominal hysterectomy declined by 64%, from 210.5 per 100,000 person-years in 2000 to 76.2 per 100,000 person-years in 2015 and those of supra-cervical abdominal hysterectomy declined by 90% from 72.3 per 100,000 persons years to 7.4 per 100,000 persons years.[3]

Vaginal hysterectomy

It was originally used only for prolapse but has become more widely used for menstrual abnormalities such as dysfunctional uterine bleeding, especially if the uterus is not more than 12 weeks size. Compared with abdominal hysterectomy, it is still regarded as less invasive and seems to have the advantages of fewer blood transfusions, less febrile morbidity, and less risk of injury to the ureter. TVH is the least invasive route for hysterectomy yet only 41% plan to use TVH as their preferred route once in future practice.[11]

Laparoscopic hysterectomy

It refers to a hysterectomy where at least part of the operation is undertaken laparoscopically. This approach requires general laparoscopic surgical expertise. The proportion of hysterectomies performed laparoscopically has gradually increased and, although the surgery tends to take longer, its proponents argue that the main advantages are the possibility of diagnosing and treating other pelvic diseases. A direct laparoscopic vision enables careful sealing off bleeding vessels at the end of the procedure, and a more rapid recovery time from surgery as compared with abdominal hysterectomy.[1]

Three subcategorizations of laparoscopic hysterectomy are as follows:

  1. Laparoscopic-assisted vaginal hysterectomy (LAVH) is where part of the hysterectomy is performed by laparoscopic surgery and part vaginally, but the laparoscopic component of the operation does not involve division of the uterine vessels.


  2. Laparoscopic hysterectomy [which we have abbreviated to LH(a)] is where the uterine vessels are ligated laparoscopically but part of the operation is performed vaginally.


  3. Total laparoscopic hysterectomy (TLH) is where the entire operation is performed laparoscopically and there is no vaginal component except for the removal of the uterus.



  ROBOT-ASSISTED HYSTERECTOMY Top


Robotic surgery, with its technical advances, promises to open a new window to minimally invasive surgery in gynecology. A pioneer in robotic-assisted surgery and maker of Da Vinci surgical systems was founded in 1995. Today, the company continues to create and refine robotic systems, giving surgeons the added benefits of technology that helps extend their capabilities. Da Vinci surgical systems are cleared by applicable regulatory agencies for use in several different procedures. The feasibility and safety of this surgical innovation have been shown in several studies, and now critical analysis of these new developments regarding outcome and costs is in place. It is a new technique with a comparable outcome to TLH. Operating times of TLH seem to be achieved quickly especially for experienced laparoscopic surgeons. However, the costs of robotic surgery are still higher than for conventional laparoscopy. The randomized clinical trials need to be conducted to further evaluate the benefits of this new technology for patients and surgeons and analyze its cost-effectiveness in gynecology.[12] It has increased 70-fold, from 0.7 per 100,000 person-years in 2008 to 48.8 per 100,000 person-years in 2015. However, it has a long learning curve and high costs.[13]


  Routes of hysterectomy global trends Top


The trends in respect of the preferred route of hysterectomy are depicted in [Figure 1].[14] It is evident now that there is a declining trend in respect of abdominal hysterectomy and a rising trend in respect of LH. This trend is likely to continue in near future.
Figure 1: Global trends in respect of routes of hysterectomy

Click here to view



  Comparative advantages and limitations of different methods of hysterectomy Top


TVH offers advantages of a shorter duration of hospital stay with faster recovery to normal activity as compared with the abdominal approach. It reduces postoperative febrile morbidity or unexpected infections. It does not have any significant benefit as compared with laparoscopy in terms of recovery, pain scoring, intraoperative, or postoperative complications. However, the vaginal approach has a shorter operative time and lower cost than the abdominal and laparoscopic approach of hysterectomy.[1]

LH provides a faster return to normal activity, shorter duration of hospital stays, fewer wound, or abdominal wall infections over abdominal approach.[3] LH is said to have improved quality of life in the first months and at 4 years postsurgery.[3] However, some of the surgeons did not find any advantage of LH over TVH.[1]

Abdominal hysterectomy has a shorter operating time, lower rate of lower urinary tract (bladder and ureter) injuries compared laparoscopic approach. However, there is no evidence of a difference in satisfaction or major long-term complications. Also, there is no evidence of a difference in overall cost in the two procedures.[3]

In an article being published in the current issue of the journal, Tondge et al. have found postoperative pain and the blood loss was substantially lesser in TVH as compared with LH. However, in my personal opinion and the opinion of some of my experienced colleagues, the postoperative pain and blood loss during surgery with LH is significantly less as compared with both vaginal and abdominal hysterectomy.


  Conclusion Top


  • Abdominal hysterectomy can be done in almost all cases barring rare conditions like frozen pelvis. In the case of unsuccessful vaginal or laparoscopic surgery, one can fall back upon abdominal hysterectomy. Therefore, an abdominal hysterectomy must be taught to every student doing postgraduation in obstetrics and gynecology.


  • TVH has lesser morbidity as compared with abdominal hysterectomy but is not ideal in the case of adnexal disease or uterus larger than 12 weeks.


  • Laparoscopic surgery is ideal in cases of adnexal disease as it gives a complete view of the abdomen and pelvis. However, it needs expensive equipment and prolonged training.


  • Robotic hysterectomy is a newer procedure and had the potential for Internet-based surgery with the surgeon operating from thousands of miles away. Probably, robotic surgery may find its uses in space travel also.


  • Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BW, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015;2015:CD003677.  Back to cited text no. 1
        
    2.
    Clayton RD. Hysterectomy. Best Pract Res Clin Obstet Gynaecol 2006;20:73-87.  Back to cited text no. 2
        
    3.
    Committee Opinion No 701: Choosing the route of hysterectomy for benign disease. Obstet Gynecol2017;129:e155-9.  Back to cited text no. 3
        
    4.
    Bachmann GA. Hysterectomy: A critical review. J Reprod Med 1990;35:839-62.  Back to cited text no. 4
        
    5.
    Sutton C. Past, present, and future of hysterectomy. J Minim Invasive Gynecol 2010;17:421-35.  Back to cited text no. 5
        
    6.
    Matthieu A. History of hysterectomy. West J Surg Obstet Gynecol 1934;8:333-49.  Back to cited text no. 6
        
    7.
    Kimball G. Successful case of extirpation of the uterus. Boston Med Surg J 1855;52:249-55.  Back to cited text no. 7
        
    8.
    Singh A, Govil D. Hysterectomy in India: Spatial and multilevel analysis. Women Health (Lond) 2021;17:17455065211017068.  Back to cited text no. 8
        
    9.
    Desai S, Shukla A, Nambiar D, Ved R. Patterns of hysterectomy in India: A national and state-level analysis of the Fourth National Family Health Survey (2015–2016). BJOG 2019;126:72-80.  Back to cited text no. 9
        
    10.
    Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu YS, et al. Nationwide trends in the performance of inpatient hysterectomy in the united states. Obstet Gynecol 2013;122:233-41.  Back to cited text no. 10
        
    11.
    Veronikis DK. Vaginal hysterectomy: The present past. Mo Med 2015;112:439-42.  Back to cited text no. 11
        
    12.
    Sarlos D, Kots L, Stevanovic N, Schaer G. Robotic hysterectomy versus conventional laparoscopic hysterectomy: Outcome and cost analyses of a matched case-control study. Eur J Obstet Gynecol Reprod Biol 2010;150:92-6.  Back to cited text no. 12
        
    13.
    Lycke KD, Kahlert J, Damgaard R, Mogensen O, Hammer A. Trends in hysterectomy incidence rates during 2000-2015 in Denmark: Shifting from abdominal to minimally invasive surgical procedures. Clin Epidemiol 2021;13:407-16.  Back to cited text no. 13
        
    14.
    Orhan A, Ozerkan K, Kasapoglu I, Ocakoglu G, Cetinkaya Demir B, Gunaydin T, et al. Laparoscopic hysterectomy trends in challenging cases (1995-2018). J Gynecol Obstet Hum Reprod 2019;48:791-8.  Back to cited text no. 14
        


        Figures

      [Figure 1]



     

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