1 Department of Obstetrics and Gynecology, Turku University Hospital, FIN-20520 Turku, 2 Department of Obstetrics and Gynecology, Oulu University Hospital, P.O.Box 22, FIN-90221 Oulu, 3 Department of Obstetrics and Gynecology, Tampere University Hospital, P.O.Box 2000, Fin-33521 Tampere, 4 Department of Obstetrics and Gynecology, Helsinki City Maternity Hospital, Sofialehdonkatu 5 A, 00610 Helsinki, 5 Department of Obstetrics and Gynecology, North Carelia Central Hospital, Tikkamäentie 16, 80210 Joensuu, 6 Department of Obstetrics and Gynecology, Kuopio University Hospital, P.O.Box 1777, FIN-70211 Kuopio, 7 Department of Obstetrics and Gynecology, Helsinki University Hospital, Haartmaninkatu 2, FIN-00290 Helsinki, Finland
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Abstract |
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Key words: complication/epidemiology/gynaecology/hysterectomy/laparoscopy
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Introduction |
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The new laparoscopic technique has been assessed against the other techniques by observational patient series, case-controlled trials and also by randomized controlled trials. The advantage of the laparoscopic approach has been mainly associated with a short hospital stay and a quick convalescence (Garcia Padial et al., 1992; Liu, 1992
; Kovac, 1995
; Weber and Lee, 1996
). There are, however, some concerns related to the costs and the morbidity of the approach (Summitt et al., 1992
; Kovac, 1995
; Weber and Lee, 1996
). In general, the results of these studies have a limited value because they are retrospective and include only a small number of patients. Furthermore, they have been performed mainly by expert surgeons or done during the learning curve of the new procedure (Garry, 1998
). In order to increase the power of the observational studies on morbidity in large numbers of patients, a prospective evaluation was conducted of all hysterectomies performed for benign indications during 1996 in the whole of Finland.
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Materials and methods |
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The complications were divided into those which occurred during operation, during hospital stay and after discharge. The morbid events were separated by type into infection, haemorrhage, thromboembolism, injury to adjacent organs (bladder, ureter and bowel), and other complications; deaths were also recorded. Infection categories included surgical site infection (wound, intra-abdominal and vaginal infections) and non-surgical site infections (lower urinary tract and other infections) and unknown fever, i.e. febrile morbidity. The haemorrhagic events were divided into wound, intra-abdominal, vaginal and non-specific bleeding problems. Other complications included nerve entrapments, hernias, cardiovascular, gastrointestinal, urinary dysfunction.
The data were collected into a common database and it was thoroughly reviewed for consistency and missed information by one of the investigators (J.J.). A total of 160 cases was rejected from the material because the final diagnosis by histology was malignant. In 6.5% of the material the information was not totally complete; separate missing data, e.g. uterine weight, estimated blood loss, experience of surgeon.
The hysterectomies were divided by approach into three groups: abdominal hysterectomy, vaginal hysterectomy and laparoscopic hysterectomy; the standard techniques of which followed the recommendations of general operative textbooks (Rock and Thompson, 1997, Garry and Reich, 1993
). Uterine fibroids and bleeding disorders were the most common indications for abdominal hysterectomy (67 and 30% respectively) and laparoscopic hysterectomy (56 and 47%) respectively, while uterine prolapse was the most common indication for vaginal hysterectomy (83%). The incidences of surgical complications were compared between these three groups of hysterectomies using relative risk (RR) and the 95% confidence intervals (CI), taking abdominal hysterectomy as the comparison term. The most common concomitant procedures, the use of prophylactic antibiotics and anti-thrombotic agents are listed in Table I
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Results |
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The rate and risk ratios of major complications in the three hysterectomy groups are shown in Table III. Urinary tract and bowel injuries and peri-operative bleeding were the most severe injuries occurring during hysterectomy. Ureter and bladder complications had a significant predominance in laparoscopic hysterectomy group, while bowel complications were most common in the vaginal hysterectomy group. The peri-operative bleedings needing surgical interventions or blood transfusions during operation were most common in vaginal hysterectomy (3.1% compared with 2.1% in abdominal hysterectomy). The occurrence of thromboembolic events and death (one in each group) was similar in all groups. Wound haemorrhages occurred mainly in the abdominal hysterectomy group but vaginal haemorrhages were more common in vaginal hysterectomy and laparoscopic hysterectomy than in abdominal hysterectomy. Infections were the most common complications with incidences of 10.5, 13.0 and 9.0% in the abdominal, vaginal and laparoscopic hysterectomy groups respectively. The highest infection rate (7.3%) was observed in urinary tract infections in the vaginal hysterectomy group.
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Discussion |
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The overall morbidity in the traditional abdominal hysterectomy (17.1%) in the present study was markedly lower than 42.8% reported previously (Dicker et al., 1982). Because infections were and are the most common complications, the difference can be explained in part by the rather high use of antibiotic prophylaxis in the present series. However, the morbidity rate in vaginal hysterectomy (23.3%) and in laparoscopic hysterectomy (19.0%) here was unexpectedly higher than that in abdominal hysterectomy which could be related to the prospective approach of the present study, and also all possible and mild complications. The total incidence of haemorrhagic events and infections was rather similar between the three groups, but urinary tract infections were clearly more common in the vaginal hysterectomy group (7.3%) than in the others. This could be due to the older age and the long use of a urinary catheter in the vaginal hysterectomy group. Otherwise, the surgical details were similar to previous reports: the operation time was longest but hospital stay shortest in laparoscopic hysterectomy, the mean uterine weight was highest in abdominal hysterectomy group and patients in vaginal hysterectomy group were older than in other groups (Boike et al., 1993
; Kovac, 1995
). The lower incidence of concomitant procedures due to endometriosis in the vaginal hysterectomy group indirectly indicates that patients assumed to have this disease were operated mostly via the abdominal or the laparoscopic approach (Table I
).
Concerning the most severe events, there was one death in each group not directly related to the operation (alcoholic cirrhosis, cardiac infarct, pulmonary embolism). These mortality rates are similar to those previously reported with gynaecological surgery in a Finnish population (Virtanen and Makinen, 1995). Regarding other severe complications, severe bowel injuries occurred more often in vaginal hysterectomy (0.5%) than in the other groups (0.2% in abdominal hysterectomy and 0.4% in laparoscopic hysterectomy). Although these differences are small and not always clinically important, bowel injuries in vaginal hysterectomy can be related to the blindness of the vaginal approach. However, most of the urinary tract lesions occurred in the laparoscopic hysterectomy group, with an incidence similar to that reported in the literature (Meikle et al., 1997
). Although the rate of urinary tract injuries was highest in the laparoscopic hysterectomy group, it was noticed that the rate of bladder (1.3%) and ureter injuries (1.1%) had declined since a previous Finnish 2 year study on laparoscopic hysterectomies in 19931994 (1.5 and 1.4% respectively) (Harkki-Siren et al., 1997
). It was also noticed that the surgeon's increased experience had an effect in decreasing the rate of severe urinary tract complications in laparoscopic hysterectomy and bowel complications in vaginal hysterectomy (Table IV
).
Choosing the type of hysterectomy for the patient should be individual, accepted by the patient and performed by a skilled surgeon with adequate equipment. In this regard, the current study is not definitive for selecting the approach for hysterectomy. This selection should be based on evidence evaluated by randomized controlled trials or even by meta-analyses of a number of such trials. The recent randomized controlled trials available in this regard compare laparoscopic hysterectomy and abdominal hysterectomy (Nezhat et al., 1992; Phipps et al., 1993
; Raju and Auld, 1994
; Marana et al., 1999
) or vaginal hysterectomy with laparoscopically assisted procedures (Summitt et al., 1992
; Richardson et al., 1995
). Furthermore, most of these studies were conducted by skilled surgeons and selected institutions in rather small series and during the learning curve of this new operative technique. Hence, these results may be biased by the lack of same surgical competence in laparoscopic hysterectomy as in abdominal hysterectomy and vaginal hysterectomy (Garry, 1998
). Consequently, at the moment the present study can be more powerful than a summation of results of a large number of small selective trials together from Medline (Meikle et al., 1997
) or literature review (Harris and Daniell, 1996
). It states morbidity figures for each operative approach of hysterectomy before new results of randomized controlled trials are available to complement, agree or disagree with the present data.
The complications of hysterectomy are not only influenced by the operator or the operative approach itself or the indication for surgery, but also by the number and type of possible concomitant procedures. In this regard the comparison of the outcome between the three hysterectomy groups showed a significantly higher rate of infectious morbidity in vaginal hysterectomy and laparoscopic hysterectomy (compared with abdominal hysterectomy) and the highest rate of organ injuries in abdominal hysterectomy when other operations were performed concomitantly. Surprisingly, the total rate of haemorrhagic events in the laparoscopic hysterectomy group decreased with concomitant procedures, which might be because they were performed by experienced surgeons.
In summary, the present observational study on a large series of hysterectomies gives novel information of morbidity in relation to the type of operative approach. This helps doctors to give advice about the expected rate of complications to their patients before planned surgery.
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Notes |
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References |
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Submitted on October 19, 2000; accepted on March 9, 2001.