Hysterectomy techniques used for benign pathologies: results of a French multicentre study

Charles Chapron1,4, Laurent Laforest2, Yann Ansquer1, Arnaud Fauconnier1, Bruno Fernandez1, Gérard Bréart3 and Jean-Bernard Dubuisson1

1 Service de Chirurgie Gynécologique (Pr Dubuisson), Clinique Universitaire Baudelocque, CHU Cochin Port-Royal, 123, Boulevard Port-Royal, 75014 Paris, 2 Direction Départementale des Affaires Sanitaires et Sociales (DDASS) du Loiret, 131 rue du Faubourg Bannier, F-45042 Orléans and 3 Unité INSERM 149, CHU Cochin Port-Royal, 123, Boulevard Port-Royal, 75014 Paris, France


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The objective of this study was to assess the techniques by which hysterectomies are carried out and to determine the rate of total laparoscopic hysterectomy (TLH). A transversal multicentre study was conducted in 23 gynaecology and obstetrics departments of French University Hospital Centres. The study population comprised only those patients for whom hysterectomy was indicated for benign disease without genital prolapse or urinary stress incontinence. Whereas the rates of performance of hysterectomy by laparotomy and by the vaginal route are comparable [respectively 40.0% (94 patients) and 46.8% (110 patients)], the rate of performance of TLH is only 13.2% (31 patients). All 23 centres (100%) carried out hysterectomy by laparotomy and 21 centres (91.3%) carried out vaginal hysterectomy; however, only nine centres (39.1%) carried out TLH. Only seven centres (30.4%) performed all three types of operation. Of the eight centres whose rate of vaginal hysterectomy was >60%, six (75%) did not carry out TLH. The study suggests that the usage of the TLH technique appears to be limited. The extent of surgical training is a major factor in the choice of technique for hysterectomy.

Key words: laparotomy/operative laparoscopy/total hysterectomy/vaginal surgery


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Hysterectomy is an operation performed frequently (Graves, 1992Go). Multicentre studies have shown clearly that it is usually carried out by laparotomy (Dicker et al., 1982Go; Easterday et al., 1983Go; Vessey et al., 1992Go; Wilcox et al., 1994Go). Vaginal hysterectomy may be offered either to selected patients (Chapron and Dubuisson, 1996Go) or because of the ability experience and preference of the operating gynaecologist to perform vaginal surgery (Querleu et al., 1993Go; Kovac, 1995Go; Han, 1996Go).

The progress in laparoscopic surgery made over the past few years has proved that total laparoscopic hysterectomy (TLH) is a feasible (Reich et al., 1989Go) and repeatable technique (Summitt et al., 1992Go; Boike et al., 1993Go; Daniell et al., 1993Go; Chapron et al., 1994Go). Laparoscopic surgery has many advantages over laparotomy, including a better cosmetic result, a significantly lower rate of infection and abdominal-wall complications, and shorter hospital stays and recovery periods. The use of laparoscopic surgery may reduce the number of hysterectomies carried out by laparotomy. In this connection, laparoscopic surgery is indicated when it enables diagnostic and/or therapeutic procedures to be performed that would be difficult if not impossible by the vaginal route (Chapron and Dubuisson, 1995Go). The use of laparoscopy may have advantages when there is a history of adhesions following surgery (Chapron and Dubuisson, 1996Go), when adnexectomy must be performed in addition to hysterectomy (Chapron et al., 1996cGo) or when vaginal access is poor (Chapron et al., 1996aGo), although none of these situations excludes the performance of vaginal surgery.

Ten years after the first TLH was performed (Reich et al., 1989Go), the purpose of this study is twofold: firstly to establish the current mode of performance of hysterectomies, and secondly to establish how widespread the performance of TLH has become. To this end we conducted a transversal multicentre study.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Hospital centres
This transversal multicentre study was conducted during May 1996 in the gynaecology and obstetrics departments of the French University Hospital Centres (CHU). A list of University Gynaecology and Obstetrics Departments was obtained from the French College for the speciality, and a questionnaire was sent to each head of department.

Patients
The study population consisted of all those patients with no malignant pathologies, no genital prolapse, and no urinary stress incontinence who were scheduled for a total hysterectomy during this period. Patients undergoing subtotal hysterectomies and obstetric emergency hysterectomies were excluded.

The following parameters were determined: the route of hysterectomy [laparotomy, vaginal route, laparoscopic surgery (TLH)], patient characteristics (age, weight, body mass index (BMI), parity, menopausal status, uterine weight, past history of surgery), indications for hysterectomy, peri- and postoperative complications, and duration of hospital stay.

Statistical analysis
Data were collected by one person at each centre and then centralized for analysis. The Pearson {chi}2 test was used to test proportions, and confidence intervals (CI) were assessed with the binomial method. Results were expressed as means and standard deviations and were compared using analysis of variance method (ANOVA). When ANOVA validity conditions were not satisfied, a non-parametric test (Kruskal–Wallis) was used. Results were considered significant when P < 0.05 (two tailed). Statistics were performed using Epi-Info 6 software.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Out of 52 departments sent the questionnaire, 23 (44.2%) agreed to take part in the study. During May 1996, 235 patients presenting no malignant pathologies, no genital prolapse, and no urinary stress incontinence underwent total hysterectomy.

The age of patients was 49.9 ± 8.7 years (mean ± SD) (range 22–83), weight was 65.6 ± 12.4 kg (range 44–121), height was 161 ± 6 cm (range 140–173), and BMI was 24.9 ± 4.7 kg/m2 (range 17.0–46.9). The parity was 2.13 ± 1.49 (range 0–9) and the number of pregnancies was 1.6 ± 2.4 (range 0–9). Sixty patients (25.5%) were menopausal (CI 95%, 20.6–32.4). Twenty-eight patients (11.9%) presented a history of abdomino-pelvic surgery (CI 95%, 8.1–16.8). The indications for hysterectomies, sometimes more than one for the same patient, are reported in Table IGo. The duration of hospital stay was 6.0 ± 2.7 days (range 2–25). The overall perioperative complications rate was 5.1% (12 cases) (CI 95%, 2.6–8.7). The overall rate of postoperative complications was 15.3% (36 patients) (CI 95%, 10.1–20.6).


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Table I. Indications* for the performance of total hysterectomy
 
The methods used for the performance of hysterectomy for these 235 patients are reported in Table IIGo. The use of laparotomy and the vaginal route was comparable [respectively 40.0% (94 patients) and 46.8% (110 patients)]. Only 13.2% of operations (31 patients) took place using laparoscopic surgery. Of the 94 hysterectomies carried out by laparotomy, six (6.4%) were conversions to laparotomy. In four cases the operation had started by the vaginal route and in two cases by laparoscopy. The rate of conversion to laparotomy is thus 3.5% (4/114) for vaginal hysterectomy and 6.1% (2/33) for laparoscopic hysterectomy. The reasons for the conversions were adhesions (3 cases), perioperative discovery of an adnexal mass (1 case), and poor vaginal accessibility (2 cases).


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Table II. Surgical procedure for total hysterectomy
 
The general characteristics of the patients grouped according to the method used for hysterectomy are reported in Table IIIGo. The age, height, and proportion of menopausal patients did not vary significantly in the three groups of patients. However, patients undergoing laparoscopic surgery had weight and BMI significantly lower than that of patients undergoing vaginal hysterectomy or laparotomy. Patients undergoing vaginal surgery had a significantly higher parity than the other two groups. The mean uterine weight was significantly higher for patients undergoing laparotomy than for those undergoing laparoscopic or vaginal hysterectomy.


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Table III. Characteristics of patients grouped according to the surgical procedure used for total hysterectomy
 
The indications for hysterectomy did not differ significantly between the three groups of patients (Table IVGo). The number of peri- and postoperative complications was greater when laparotomy was performed (Table VGo). For the patients who experienced no complications, the duration of hospital stay was statistically correlated with the operative technique (P < 0.00001). The mean duration of hospital stay was 4.1 ± 1.7 days for TLH, 4.9 ± 1.7 days for vaginal hysterectomy, and 6.9 ± 2.1 days for laparotomy.


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Table IV. Indications for hysterectomy of the groups of patients categorized according to the surgical procedure
 

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Table V. Rate of complications of the groups of patients categorized according to the surgical procedure
 
The number of operations and the technique by which hysterectomy was carried out varied considerably from one centre to another (Table VIGo). The mean number of hysterectomies carried out per centre was 10.2 ± 4.5, ranging from three (centre 15) to 22 (centre 21). All centres carried out hysterectomy via laparotomy and all except two (91.3%) (centres 2 and 21) carried out vaginal hysterectomies. Only nine centres (39.1%) carried out TLH only and only seven centres (30.4%) used all three types of operation. Of the eight centres with a rate of vaginal hysterectomy of >60%, six (75%) did not perform operative laparoscopy.


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Table VI. Surgical procedure used to perform total hysterectomy in the 23 centres
 
Only 13.2% of operations (31 cases) were carried out by laparoscopy. This technique was not used in 61% of centres (14 teams). Seventy-one per cent (22/31) of the TLH were carried out in 13% of the centres (nos 20, 21, 23). These three teams performed a mean number of 7.3 TLH per month, representing 55% of all hysterectomies (22/40). One of these three centres (no. 22) carried out nearly 70% of hysterectomies by laparoscopy (15/22) and performed half (15/31) of the laparoscopic hysterectomies of the whole study. The six other centres performing TLH carried out a mean of 1.5 per month (9/6), representing only 12% of operations (9/75).


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
This study suggests that the technique of total laparoscopic hysterectomy (TLH) has not achieved widespread use and the rate varies between centres.

The mean number of hysterectomies carried out by operative laparoscopy was low (13.2% of operations; 31 cases) and TLH was not carried out by two-thirds of the centres (61%; 14 teams). This cannot be explained by the risk of complications. Operative laparoscopy is a safe procedure if the surgeons are well trained (Chapron et al., 1998Go) and the number of complications is not greater than that observed with laparotomy or the vaginal route (Dorsey et al., 1995Go; Johns et al., 1995Go; Nezhat et al., 1995Go; Chapron et al., 1996bGo). There is also considerable variation between the centres that do use TLH. Ten years after the first case of TLH was published (Reich et al., 1989Go), this operative procedure appears to be performed either where the team is particularly interested in laparoscopic surgery (centres 20, 21, 23) or where the team is learning these new techniques (centres 1, 2, 8, 17, 19, 22).

The methods for carrying out hysterectomy vary considerably from one centre to another (Table VIGo). Whereas all the centres carried out this operation by laparotomy, its use varied from 9.1% (centre no. 18) to 90% (centre no. 2). Similarly, although 91% (21/23) of the centres used vaginal hysterectomy, the rate varied from 20% (centre no. 5) to 91% (centre no. 18). These differences suggest that the training of the surgeons plays an essential parameter in determining the choice of technique (Kovac et al., 1991Go). The use of laparoscopic surgery appears to be inversely proportional to the ability of the team to perform vaginal surgery. Three out of four of the centres carrying out at least 60% of hysterectomies by the vaginal route used no TLH at all. Similarly the mean rate of vaginal hysterectomies for the nine centres carrying out TLH was 39% (34/115) which is lower than the overall mean rate.

These results were obtained in 23 French University Gynaecology and Obstetrics Departments, and appear to be an indication of the means by which hysterectomies are carried out in France. Whether the hospital structure is private or public, or linked to a University or not, appears to be irrelevant. Another prospective multicentre study was carried out between 2 and 15 December 1996 in France to assess the spread of laparoscopic surgery (Mabille de Poncheville, 1998Go). During this period 1350 surgeons responded to the questionnaire and carried out 1336 hysterectomies (Table VIIGo). The number of hysterectomies performed using laparotomy and by the vaginal route did not depend upon the type of hospital in which the procedure was performed. The rate of TLH was low, being significantly lower in private clinics (1.5%) (P < 0.0001), but comparable in public hospitals regardless of whether they were teaching hospitals (11.5%) or not (9.6%) (Table VIIGo).


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Table VII. Surgical procedures used to perform total hysterectomy in French general non-teaching hospitals (GNTH), university hospitals (UH), and private clinics (from Mabille de Poncheville, 1998)
 
Although the technique of operative laparoscopic hysterectomy has not achieved widespread use, the methods used for hysterectomy have changed. The past 10 years have seen a drop in the number of hysterectomies carried out by the abdominal route. Multicentre studies carried out a few years ago (Dicker et al., 1982Go; Easterday et al., 1983Go; Vessey et al., 1992Go; Wilcox et al., 1994Go) reported that three-quarters of all hysterectomies took place via the abdominal route. This has now fallen to 40%, and a similar change has been observed in the United States (Harris and Olive, 1994Go; Dorsey et al., 1995Go; Johns et al., 1995Go) (Table VIIIGo). However, although the number of abdominal hysterectomies has fallen, there is regional variation in the techniques used to replace it. In France it has been replaced by vaginal surgery, since 46.8% of hysterectomies were carried out using this route. In the United States, however, although the introduction of laparoscopic surgery has indeed brought about a decrease in the use of abdominal surgery (45.4%), the proportion of vaginal hysterectomies has remained constant (25%) (Harris and Olive, 1994Go; Dorsey et al., 1995Go; Johns et al., 1995Go). This trend is far from being universal. For example Finland (Härkki-Sirèn et al., 1998Go) and Great Britain (Davies et al., 1998Go) retain high rates of abdominal hysterectomy (83.8 and 71.7% respectively).


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Table VIII. Surgical procedures used to perform hysterectomy: review of the literature
 
Certain teams have a preference for vaginal surgery (Querleu et al., 1993Go; Kovac, 1995Go; Han, 1996Go) while others exhibit a distinct orientation towards laparoscopic surgery (Reich et al., 1989Go; Nezhat et al., 1995Go; Chapron et al., 1996bGo). However, provided the surgeon has sufficient experience it is possible to reduce the number of hysterectomies performed by laparotomy very considerably.

The failure of TLH to achieve widespread use suggests that the technique has not been properly taught and/or that its advantages compared with laparotomy have not been fully appreciated. The task that should be achieved over the years to come is certainly not to recommend one technique rather than another (vaginal route or operative laparoscopy) but rather to ensure that young surgeons can be offered training in all three techniques: laparotomy, vaginal surgery, and operative laparoscopy. The only way to decrease the number of laparotomic hysterectomies is to enable all three types of approach to be used efficiently (Figure 1Go) by providing fully comprehensive surgical training.



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Figure 1. Appropriate surgical technique for hysterectomy in patients with a non-prolapsed uterus (Chapron and Dubuisson, 1996).

 
Multicentre studies have indicated the continuing prevalence of laparotomic hysterectomy, and the increased use of laparoscopic and vaginal surgery is the only way of combating this.


    Acknowledgments
 
The authors gratefully acknowledge the French teams that have collaborated in this study:

Prof. Berger (Tours); Prof. Bernard and Prof. Racinet (Grenoble); Prof. Body (Tours); Prof. Brettes (Strasbourg): Prof. Boulanger (Amiens); Prof. Crépin (Lille); Prof. Dargent (Lyon); Prof. Dubuisson (Paris); Prof. Engelman (Colombes); Prof. Frydman (Clamart); Prof. Grosieux (Angers); Prof. Landes (Nancy); Prof. Leng (Bordeaux); Prof. Lopes (Nantes); Prof. Madelenat (Paris); Prof. Magnin (Poitiers); Prof. Maillet (Besancion); Prof. Paniel (Créteil); Prof. Piana (Marseille); Prof. Pigné (Paris); Prof. Quereux (Reims); Prof. Raudrant (Lyon); Prof. Rudigoz (Lyon). The teams are listed in alphabetical order and are not coincident with the listing order of Table VIGo.


    Notes
 
4 To whom correspondence should be addressed Back


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Boike, G.M., Elfstrand, E.P., Del Proiore, G. et al. (1993) Laparoscopically assisted vaginal hysterectomy in a university hospital: Report of 82 cases and comparison with abdominal and vaginal hysterectomy. Am. J. Obstet. Gynecol., 168, 1690–1701.[ISI][Medline]

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Submitted on March 19, 1999; accepted on June 18, 1999.