Introduction
Next to Caesarean delivery, hysterectomy is the most frequently performed gynecological surgery [
1]. Each year, more than six million hysterectomies are performed worldwide [
2]. Rather than curing life-threatening conditions, most hysterectomies are performed to improve the quality of life of patients [
3]. Some studies have reported that life-threatening indications for hysterectomies, such as pre-invasive and invasive gynecological cancer and obstetrical hemorrhage, represent only 10%–15% of all cases. The most common indication for hysterectomy is uterine myoma.
Rates of hysterectomy vary significantly among regions, races and ages [
3]. This is largely because of differences in the availability of other therapies, such as pharmacological therapy and minimally invasive surgical techniques that may improve symptoms while providing a less-invasive alternative to hysterectomy [
4]. Treatment also varies widely by age. If possible, it is always preferable to retain the uterus in young nulliparities, whereas hysterectomy can be considered for postmenopausal women. The goal is to choose the therapy that gives the patient the best outcome at the lowest cost with the least amount of pain. However, there has been no universal agreement regarding strict criteria for hysterectomy, and treatment is currently tailored for individual women. The purpose of this study was to compare surgical indications and surgical approaches by age group, in order to provide physicians with some guidance about optimal treatment selection.
When hysterectomy is unavoidable, the first question to be considered by the physician is the best surgical approach. There are four main approaches of hysterectomy: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and laparoscopically assisted vaginal hysterectomy (LAVH) [
5]. Each of these surgical approaches has its advantages and disadvantages. Historically, the approach was chosen according to a woman’s health condition and underlying disease. For example, AH has been used for widely metastatic disease and for very large pelvic masses. In contrast, VH was performed for prolapse and for menstrual abnormalities when the uterus was of relatively normal size because it was less invasive than AH [
6]. Significantly speedier return to normal activities and other improved secondary outcomes suggest that laparoscopic hysterectomy is preferable to abdominal hysterectomy where possible, although LH and LAVH are both costlier and require greater surgical expertise than traditional abdominal approaches [
2].
The various surgical approaches have different effects on patients’ short-term and long-term post operative quality of life [
7]. Although it takes a longer amount of time for patients to recover from AH, this approach is also associated with fewer operative complications. With regard to VH, the benefits of the traditional vaginal approach over LH and LVAH include a lower expense and a shorter operation time, with similar outcomes. Apart from the increased incidence of urinary tract injuries in LH compared with AH, no significant differences seem to exist between these surgical approaches for terms of the risk of intraoperative visceral injuries [
8].
Robotically assisted hysterectomy (RAH) has recently been introduced as a minimally invasive alternative approach to hysterectomy [
9]. The robotic surgical platform received approval from the US Food and Drug Administration in 2005 for performing gynecological procedures, allowing a surgeon to perform the procedure at a remote console [
10]. Compared with open surgery, RAH offers such benefits as a decreased length of hospital stay and a decreased blood transfusion volume [
11]. The robotically assisted approach and the laparoscopic approaches have similar morbidity profiles, but the use of robotic technology is substantially more expensive [
12]. At the present time, few reports on the use of RAH in China exist.
Another factor that must be considered when planning hysterectomy is whether to retain the ovaries or not. The relative merits of hysterectomy methods for concomitant bilateral oophorectomy for benign disease had been extensively investigated [
9–
11]. For menopausal women, simultaneous oophorectomy with hysterectomy had traditionally been recommended when possible [
13], with the goal being to decrease the 1% lifetime risk of ovarian cancer. For non-menopausal women, on the other hand, oophorectomy has been discouraged on the grounds that it would impair both sexual desire and sexual function, especially in women aged<45 years. All of these risks and benefits need to be discussed with patients prior to making a decision about removal of the ovaries.
It is estimated that there are approximately one million hysterectomies performed each year in China. However, national data about the indications for and the surgical approaches to hysterectomy in China are lacking. This study was undertaken to determine the most common surgical indications for hysterectomy by age and surgical approach at Tongji Hospital of the Huazhong University of Science and Technology from 2004 to 2009. We also wished to evaluate the rates of concomitant bilateral oophorectomy to reflect on the current status of hysterectomy and provide reference data for gynecologists and other researchers. Finally, our goal was to discuss the relative merits of the different surgical approaches and provide some suggestions for patients and clinicians, so as to assist with choosing the best treatment plan and surgical approach.
Patients and methods
All 4653 hysterectomy cases in Tongji Hospital from 2004 to 2009 were selected for analysis. The following age categories were used to analyze data by the age (in years) of women at the time of surgery:<20, 20–29, 30–39, 40–49, 50–59, 60–69 and≥70 years. The 4 categories of surgical approaches were AH, VH, LH and LAVH. All diseases and surgical approaches were defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The ICD-9-CM procedure codes of 68.3, 68.4 or 68.5 indicated simple hysterectomy; 65.5 or 65.6 indicated concomitant bilateral oophorectomy; and 54.21 indicated a laparoscopy. We recorded every diagnosis when multiple diagnoses were listed. Length of hospital stay, operating time, volume of blood loss and volume of blood transfusion were recorded for each case. Statistical analysis was performed using analysis of variance (ANOVA) and the chi-square test. Statistical significance was set at P<0.05. The analyses were performed using SPSS ver. 18.0 (SPSS Inc., Chicago, IL, USA), and the figures were created using SigmaPlot ver.12.0 (Systat Software Inc., San Jose, CA, USA).
Results
There were a total of 4653 hysterectomy procedures performed at our institution from 2004 to 2009. Characteristics of all patients, stratified by age group, were shown in Table 1. By far, the greatest number of hysterectomies were performed on women aged 40–49 years (2299, 49.4%). Young women (age≤39 years), and particularly those aged<20 years, were noted to be significantly younger at menarche than those in the older age groups. Furthermore, women aged 40–49 years had significantly shorter menstrual cycles than others (P<0.05), although there were no significant differences in the duration of menstruation within each cycle between the seven groups. Approximately 35% of all subjects who had hysterectomies also had a concomitant bilateral oophorectomy. The lowest rate of oophorectomy was in women aged 30–39 years (15.8%), whereas the highest was in those aged 50–59 years (75.9%). Furthermore, both the two youngest groups and the three oldest groups were significantly more likely to undergo concomitant bilateral oophorectomy than women in the intermediate age ranges (30–49 years).
Data regarding the indications for inpatient treatment for hysterectomy in each age group were presented in Table 2. Because some cases listed multiple indications, the total N in these data (5480) exceeded the total number of cases (4653). Overall, colporrhagia and abdominal pain were the 2 most common indications for surgery in the general study population. In younger and middle-aged women, the primary indications for hysterectomy were colporrhagia, abdominal pain and abdominal mass, whereas in older women, especially those aged≥70 years, uterine prolapse became the most common complaint for hysterectomy.
All diagnoses were counted when multiple diagnoses were listed for one case; as such, 5729 diagnoses were listed altogether. The top four most common final diagnoses were presented for each age group, followed by the number of cases that indicated a malignant etiology (Table 3). In young women (up to age 39 years), the most common diagnosis was a malignant tumor of the ovary (age<20 years) or uterus (age 20–39 years); in women ages 40–59 years, uterine myoma was the most frequent; and among women aged≥60 years, uterine prolapse was the leading diagnosis. The proportion of cases with a malignant etiology also varied by age, being highest in women aged<20 years (75.0%) and lowest in those aged 40–49 years (19.9%).
The abdominal surgical approach was used in 3905 cases of all hysterectomies, accounting for 83.9%. The cases of LH was 482, accounting for 10.4% of all, whereas the cases of VH was 215, accounting for 4.6% and the cases of LAVH was 51, accounting for 1.1%. A breakdown of outcomes associated with the four different approaches to hysterectomy were presented in Fig. 1A–1D. The mean hospital stay for women undergoing AH was 20.5 days, which was significantly longer than that in women undergoing surgery using the other 3 approaches. The VH cases required a significantly shorter amount of operating time (average, 118 min) than all the others. Both the amount of bleeding and the required blood transfusion volume were also smaller in VH, although the differences were not statistically significant. The average age of women undergoing AH was 45.5 years, which was smaller than the mean 59.4 years for VH and greater than the mean 43.7 years for LH (P<0.05) (data not shown). The surgical approaches used were also related to the size of the scope of surgery, as illustrated in Fig. 1E. For the smallest scope of surgery, which was subtotal hysterectomy, LH was commonly used, whereas for the widest scope of surgery, i.e., hysterectomy with concomitant bilateral oophorectomy, AH was used more often.
Discussion
Hysterectomy is a common surgery performed for a wide range of gynecological dysfunctions. For conditions such as severe uterine prolapse and dysfunctional uterine bleeding that strongly affect the quality of life of patients, hysterectomy improves symptoms; in addition, clinical research has demonstrated that these surgical procedures have both short-term and long-term benefits [
3].
Worldwide, the most common indication for hysterectomy is uterine myoma, although this varies by age and race [
1,
14,
15]. Our data showed the same result. This finding is probably attributable to a combination of two factors: the high occurrence of uterine myoma overall, and the serious effects that its symptoms have on quality of life.
Nearly half of all the women who had a hysterectomy in our study were between the ages of 40 and 49 years, and this finding is consistent with previous reports [
1,
16]. With regard to primary complaints, abdominal pain and abdominal mass were the most common among young women, colporrhagia among middle age women and uterine prolapse among the elderly; these were consistent with the indications for hysterectomy. These results seem logical considering that, in many cases, only a malignancy would prompt a young woman to undergo radical hysterectomy, rather than opting for a less invasive option that could preserve her uterus for future fertility. In contrast, because most of the middle-aged women had completed childbearing, hysterectomy may have seemed like a more viable option, even for benign conditions such as uterine myoma and adenomyosis, in order to avoid the potential for malignant transformation. In conclusion, the main indication for hysterectomy differed between age groups in the present study.
The above data suggested that once the symptom of colporrhagia or abdominal pain occurred, if more attention could be paid and the women took some preventive or pharmaco therapeutical measures, some cases of hysterectomy might be avoided. From the study data, it was observed that the two age groups of<20 years and 20–29 years accounted for 2.8% of the total. Majority of these women had not given birth and required surgery for uterine or ovarian cancer. This caused a loss of fertility, which was a huge sorrow for the patients and their families. If clinical and research workers in gynecology can develop treatment strategies to help preserve fertility after the surgery, it can benefit many patients. This aspect was also a significant consideration of this study.
Among the four major types of hysterectomy now used [
17], AH remains the most common approach. Compared with VH and AH, the advantages of LH include less blood loss, a shorter hospital stay, a speedier return to normal activities and fewer abdominal wall infections or febrile episodes [
5]. More recently, LAVH has been developed for certain indications, with the primary advantage of this approach being that it is faster than traditional LH [
18].
Reported complications after hysterectomy also varied according to the approach. For example, one study reported that the volume of blood loss was highest in AH, whereas the volume of transfused blood required was higher after LH than after VH [
2]. Our findings were similar to those of previous investigations, albeit with some differences. Our data were consistent with several previously reported advantages of VH, such as decreased blood loss and blood transfusion volume, a shorter hospital stay and shorter operating time. However, in our study population, AH remained the most common approach for hysterectomy because the use of LH and VH was limited by the fact that they could only be performed for special indications. Another reason for the frequency of AH in our study was the scope of surgery. As a tertiary care hospital, we treat a large proportion of malignant tumors, and these cases necessitate a high proportion of abdominal approaches. In conclusion, indications for hysterectomy, patient mix, cost considerations and physician skill all must be taken into account when selecting the most appropriate approach for hysterectomy.
The limitation of this study was that when pros and cons of the four different surgical methods were evaluated, there was no match for confounding factors. After further analysis of the data, it was learned that in the four surgical methods, the average age of patient for VH group was the highest (average age was 59.4 years). This difference had a statistical significance compared with the other three groups, whereas the differences of the other three groups showed no statistical significance. This may be because VH is primarily performed in patients with uterine prolapse who are generally older. However, based on the data limitations, we could not match and calibrate the pre-existing diseases of patients. We believe we need further prospective randomized controlled studies to match the confounding factors of patients’ ages and indications of surgery to get reliable conclusions.
The decision to remove or conserve the ovaries at the time of hysterectomy has different consequences for both short-term and long-term health [
19–
21]. Prophylactic bilateral oophorectomy at the time of hysterectomy significantly decreases the risk of ovarian cancer in all women, whether or not they are at increased risk for ovarian cancer. On the other hand, bilateral oophorectomy in premenopausal women can cause hormone-induced dysfunctions, including vasomotor symptoms, cardiovascular health risks, cognitive function decline and mental health problems, osteoporosis and fracture risk and sexual dysfunction [
22–
24]. The advantages and disadvantages of removing the ovaries should be weighed carefully before the surgical procedure.
In our study, the bilateral oophorectomy rates were distributed in a reverse bell curve, with the women aged <20 years and those aged>50 years having higher rates of bilateral oophorectomy. In the younger women, the high incidence of malignant ovarian diseases often necessitated the removal of both ovaries. For postmenopausal women, on the other hand, bilateral oophorectomy may have been a reasonable choice, considering the already significantly decreased ovarian endocrine function, combined with the motivation to prevent ovarian cancer [
25].
One-third of the hysterectomies in our institution were accompanied by bilateral oophorectomy for malignant or benign diseases. For women aged>50 years, the ratio of prophylactic oophorectomy with hysterectomy was high in our data. It is essential to investigate potential impact on long-term risks of breast and ovarian cancers, coronary artery disease, osteoporosis, depression and the likely efficacy and safety of hormone therapy in these women who underwent oophorectomy. Larger prospective studies are needed to define the risks and benefits of oophorectomy at the time of hysterectomy.
Conclusions
The main indication for hysterectomy in our study was uterine myoma, and approximately 35% women had concomitant bilateral oophorectomy. The surgical indications and the rates of bilateral oophorectomy varied by age. The most common surgical approach to hysterectomy was abdominal, although in term of operating time, length of hospital stay, blood loss and blood transfusion volume, the vaginal approach was superior to the other surgical approaches. It is of great importance to trace the long-term health of this cohort.
Higher Education Press and Springer-Verlag Berlin Heidelberg
PDF
(231KB)
