Hysterectomy, a comparative study of the different Hysterectomy Routes 2002-2010 : a retrospective analysis for 954 patients
Background and aims: The aim of this study is to compare the data of patients and the operating parameters of the five different surgical techniques of hysterectomy (VH = vaginal hysterectomy, AH = abdominal hysterectomy, TLH = total laparoscopic hysterectomy, LASH = laparoscopic supracervical hysterectomy, LAVH = laparoscopic-assisted vaginal hysterectomy). Methods: Patients A total of 954 patients underwent a hysterectomy in the period from January 2002 to October 2010 for benign uterine disease. Material: The data were retrospectively collected from patients’ records and analyzed. The evaluated data included patient’s age, BMI, parities, former operations, indications of operation, duration of hospital stay, operating time, weight of uterus, histopathological report of removed specimen, hemoglobin fall and intra- and postoperative complications. Statistical analysis A statistical analysis was used to examine differences within the five groups concerning the analyzed parameters. Demographic and surgical data were analyzed by ANOVA, Kruskal- alis-, hi-square- or Fisher s test. Results: The average age recorded for all hysterectomies was 47.95 years and the average BMI was 25.85. By comparing all methods, the most common indications for hysterectomy were uterine myoma (65.2%), adenomyosis (11.2%), prolapse (14.8%), hyperplasia of uterus and cervix (2.0%), menstrual disorder (14.8%) and endometriosis (5,0%). The hospital stay was the longest for AH (7.92 days) and the shortest for LASH (3.88). For VH the average hospital stay was 6.74 days, for LAVH 5.85 and for TLH 4.32 days. The shortest operating time was for VH (76.03 minutes) and the longest for LAVH (137 minutes). For AH the average operating time was AH 107.71 minutes, for LASH 106.59 and for TLH 130.24 minutes. The average uterine weight was heaviest for AH 518.58 (170.00- 721.50) grams and lightest for VH 127.77 (59.50-168.50). The average uterine weight for LASH was 244.92 (118.00- 310.00), for LAVH 159.24 (100.50- 181.00) and for TLH 205.11 (114.00- 224.00). The lowest average hemoglobin decrease for LASH was 0.70 g/dl, for AH 1.63 g/dl, where as for VH it was 1.29 g/dl, for LAVH 1.83 g/dl and for TLH 0.82 g/dl. The lowest complication rate was recorded for LASH (2.4%) and the highest for AH (6.6%). The complication rate for VH was 6.3%, which was higher than TLH (2.9%) and slightly lower than LAVH (6.4%). The two well established laparoscopic techniques for hysterectomy (LASH and TLH) showed a lower complication rate than VH and AH. The intraoperative complication rate for hysterectomies operations was 2.9%. The highest intraoperative complication rate occurred at abdominal hysterectomy (4.5%) and the lowest at TLH (1.5%). Postoperative complications are classified into two major groups; major and minor complications. The major postoperative complication rate was 1.8% and the minor postoperative complication rate was 5.9 %. The highest incidence of major complications was recorded by LAVH (6.4%) and the lowest by LASH (1.2%). The lowest minor postoperative complication rate was recorded by LASH (1.8%) and the highest by AH (8.4%). Conclusions Patients with uterine myomas, endometriosis, additional adnexal pathology and high BMI benefit from the laparascopic access route in comparsion to AH and VH. Patients with prolapse, a higher parity score and a low preoperative score benefit from VH compared to LH and AH. VH is a safe natural orfice route for patients with a large number of vaginal delieveries and a low uterine weight. The operation duration is significantly shorter and postoperative results are comparable to laparoscopic hysterectomies. LASH and TLH are minimally invasive methods showing the lowest intraoperative and postoperative complication rate especially for patients with a high preoperative score and a high uterine weight. Laparoscopic hysterectomies showed the lowest hemoglobin decline and the shortest hospital stay and therefore should be the method of choice if VH is not possible. Intraoperative complications correlated with the increase in uterine weight, while no important correlations between BMI, age and uterine weight were observed. The hospital stay was statistically tested against the BMI. However, showed no significant correlation LASH and TLH are associated with a generally lower rate of complications in comparsion to AH and VH. The growing prevalance of obesity, late first delivery and the increase in the preoperative score have contributed to an increased rate of laparoscopic hysterectomies.