Download Guidelines for Hysterectomy

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Guidelines for Hysterectomy
S.R. Kovac
Emory University School of Medicine, Atlanta, Georgia, U.S.A.
Gynecologic surgeons worldwide continue to use the abdominal approach for a large
majority of hysterectomies that could be performed vaginally despite well-documented
evidence that vaginal hysterectomy has distinct health and economic benefits in terms of
fewer complications, better postoperative quality-of-life outcomes, and reduced hospital
charges. Because abdominal hysterectomy is associated with less favorable medical
outcomes, evidence supports its use only when documented pathologic conditions
preclude the vaginal route.1,2,3,4 However, some surgeons remain reluctant to change their
practice patterns, and continue to select the abdominal route for most hysterectomies
without documenting that the vaginal route is contraindicated. The algorithm in Figure15
offers gynecologic surgeons a structured approach for selecting the appropriate surgical
technique. Using a formal decision process to determine the route of hysterectomy has
shown that evidence-based guidelines could potentially save 1.2 million dollars for every
1000 hysterectomies performed, would free up 1020 patient bed days, and reduce
complications by 20%. Adherence to these guidelines should enable physicians to
perform 80% of hysterectomies via the vaginal route, dramatically reducing the current
3:1 abdominal/vaginal ratio.6
Because we have neglected to adopt evidence-based formal practice guidelines for
hysterectomy surgeons all too often choose a route of hysterectomy based on their own
personal preference justifying the appropriateness of their choice. Thus surgeons often
select vaginal or abdominal hysterectomy for similar conditions without determining the
evidence supporting one procedure over the another.
The American College of Obstetricians and Gynecologists (ACOG) tentatively addressed
this problem by issuing a statement that vaginal hysterectomy is best performed in
women with mobile uteri no larger than 12 weeks’ gestational size (~280 g). ACOG
continued by acknowledging by committee opinion that the choice of hysterectomy
approach should be based on the surgical indication, the patient’s anatomic condition,
data supporting the chosen approach, informed patient preference, and the surgeon’s
expertise and training 5 Figure 2). Furthermore, ACOG acknowledges that the desire
ratio for cases performed vaginally versus abdominally should be 70% by the vaginal
route and 30% abdominally. 7 Unfortunately, these recommendations have never been
subjected to critical review and current evidence suggest that a physician’s expertise and
training may be the only consideration in selecting the route of hysterectomy. This has
resulted in a current ratio obtained from NHDS in 1999 of 63.8% of hysterectomies
performed abdominally and 23.6% vaginally. 8
Historically, abdominal hysterectomy is accepted to be appropriate for more serious
diseases that necessitate this approach. However, traditional teaching predisposes
surgeons to select the abdominal route despite pathologic indications. Further
compounding the problem many of the traditional indications for selecting an abdominal
hysterectomy were never subjected to vigorous review and in many cases have been
shown to be invalid (figure 2).9 Performing abdominal hysterectomies for less serious
conditions subject women to greater risks of complications, longer recuperation and
poorer postoperative quality of life outcomes. Vaginal hysterectomy has been regarded as
contraindicated when the vaginal route is presumed to be inaccessible or when more
serious pathologic conditions such endometriosis, pelvic adhesive disease, adnexal
pathology, chronic pelvic pain, and chronic pelvic inflammatory disease are thought to
exist. In addition, many surgeons hesitate to perform vaginal hysterectomy in nulliparous
women, in women who have had previous pelvic surgery (including one or more cesarean
sections), in those with a moderately enlarged uterus, or when oophorectomy is to be
performed concurrently.
Traditional indications for abdominal and contraindications for vaginal hysterectomy
must be reevaluated on the basis of currently available data. For example, for many years
the literature has shown that the ovaries can be removed transvaginally in most women
undergoing vaginal hysterectomy. In numerous studies, prophylactic vaginal
oophorectomy was successfully performed in 95% of patients. Ovaries that descend into
the vagina when the infundibulopelvic ligament is stretched are usually visible and
accessible for transvaginal removal, even if the descent is partial. In 966 women
undergoing vaginal hysterectomy it was found that the ovaries were or could have been
removed vaginally without laparoscopic assistance in more than 99%.10 The common
belief that the ovaries must be removed by the abdominal route or via operative
laparoscopy is a myth that can no longer be tolerated if no valid contraindications to
transvaginal ovarian removal can be documented.
The selection of abdominal hysterectomy for more serious pathologic conditions has been
a de facto guideline that has gone largely unchallenged. Surgeons do not always select
the route and method of hysterectomy based on documentation of the severity of the
pathology. Rather, mere suspicion of pathology frequently dictates the approach used.
Although information in the gynecologic literature comparing the preoperative diagnosis
of hysterectomy with pathologic results is sparse, there is sufficient evidence that the
presumptive preoperative diagnosis is often inaccurate, representing a diagnosis treatment
discrepancy.
Continued reliance on abdominal hysterectomy despite well-documented studies
disputing its efficacy has been attributed to several nonclinical factors that create a
discrepancy between the state of current practice and our knowledge regarding the best
standard of care. As noted earlier, evidence-based formal practice guidelines have not
been adopted that clearly identify appropriate candidates for abdominal hysterectomy,
vaginal hysterectomy, or laparoscopic assistance to complete a vaginal hysterectomy.
Insufficient training and experience in vaginal and laparoscopic techniques have also
been cited. Misperceptions have contributed further to the confusion. Many surgeons
simply feel more comfortable with the abdominal route in nulliparous women, when the
uterus is enlarged, in the absence of uterine prolapse, or when oophorectomy is required.
Physician practice styles favoring a single route or method have been allowed to go
unchallenged despite the pressure for more cost-effective health care. This bias can no
longer be accepted.11
Several outcome-based studies show that vaginal hysterectomy can be successfully
performed in approximately 77% to 94% of patients with benign disease by using a
formal decision-making process to determine the route of hysterectomy.2,3,4 Three critical
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questions must be answered before selecting the surgical route of hysterectomy for
patients with benign disease.
1.Can the uterus be removed transvaginally?
2.Is the pathology confined to the uterus or does it extend beyond the confines of the
uterus?
3.Is laparoscopic assistance required to facilitate vaginal removal of the uterus?
Transvaginal Accessibility
A major factor in determining the route of hysterectomy is transvaginal accessibility of
the uterus. Inadequate accessibility sustaining from a narrowed vagina at the vaginal apex
makes vaginal hysterectomy technically challenging and may contraindicate vaginal
hysterectomy, especially by surgeons less experienced in this procedure. Two factors
limit accessibility: an undesended and immobile uterus and a vagina narrower than 2
fingerbreadths, especially at the apex. Gynecologic surgeons should be alert for these
indicators when examining patients. A narrowed pubic arch, frequently suggested as a
contraindication to vaginal hysterectomy has never been proven to be a deterrent to the
vaginal route. Nulliparity is not an absolute contraindication to vaginal hysterectomy.
Although access to the vaginal vault may be restricted in some nulliparous women,
inaccessibility cannot be assumed in all cases. In fact, there is no evidence in the
literature to support the widely held belief that nulliparity makes vaginal hysterectomy
difficult. If accessibility appears adequate, the women may be a candidate for a vaginal
hysterectomy with or without laparoscopic assistance.
Uterine Size
Gynecologic surgeons have long considered an enlarged uterus a contraindication to
vaginal hysterectomy, but the term enlarged has not been clearly defined. A normal-size
uterus weighs approximately 70 to 125g. ACOG and other investigators assert that vaginal
hysterectomy is indicated in women with mobile uteri no larger than 12 weeks’ gestational
size (~280g), suggesting that uteri greater than 280g are appropriately performed by the
abdominal route.12 Coring, bivalving, and morcellation are well-accepted methods of
reducing an enlarged uterus so that it can be removed transvaginally. However, studies
show that in reality between 80% and 90% of all uteri removed for various indications
weigh 280g or less and do not require reduction technique for vaginal removal.
Several investigators reported using pharmacologic agents to reduce the size of the uterus
preoperatively when necessary. In clinical studies patients with pretreatment uterine sizes
ranging from 14 to 18 weeks’ gestational size, the administration of gonadotropinreleasing hormone analogues reduced the size of symptomatic uterine leiomyomata by
30% to 50% and decreased uterine volume by approximately one third before
hysterectomy in patients with enlarged uteri who would have been candidates for
abdominal hysterectomy.
The size of the uterus in vivo usually can be measured by simple physical examination. If
there is still a question about uterine size, transvaginal ultrasound is another option. An
algebraic formula is used to determine the uterine size, expressed in weights and
measurements. By multiplying the three dimensions of the uterus in centimeters (length
X width X anteroposterior diameter at the fundus) by 0.52, physicians can estimate the
mass of the uterus in grams in order to obtain a more accurate preoperative estimate of
uterine size.13 Example: 6cm X 6cm X 8cm X 0.52 = 149g.) Preoperative documentation
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of uterine size in vivo can help to prevent abdominal hysterectomy being selected
unecessarily.
Extent of Pathology
Determining whether the pathology is confined to or extends beyond the confines of the
uterus is critical to selecting the most appropriate route of hysterectomy. According to the
algorithm, a vaginal hysterectomy is indicated when pathology is confined to the uterus
and the uterus is <280g. When the preoperative diagnosis suggests that the pathologic
condition extends beyond the confines of the uterus, laparoscopic evaluation can help
determine the severity of the condition before deciding whether to remove the uterus via
the vaginal or abdominal route.
Traditionally, gynecologic surgeons used the results of the history, physical examination,
and imaging techniques, such as ultrasound and x-ray studies, to determine whether the
pathology extended beyond the uterus. However, several investigators7,8 have proved that
these techniques are not sufficiently accurate to adequately document the severity of
those conditions, especially endometriosis, adnexal pathology, chronic pelvic pain, and
pelvic inflammatory disease. Such preoperative examinations are not sufficiently accurate
to allow us to make precise surgical decisions. When surgeons based their decision to
perform an abdominal hysterectomy on the clinical history and pelvic examination
without further intraoperative documentation of the severity of the patient’s condition, the
surgical findings often did not support the selection of the abdominal route, again a
diagnosis/treatment discrepancy. Not only is the laparoscope useful for accurately
assessing the extent and characteristics of the disease, it is also valuable in determining
the mobility of the uterus and adnexal structures. Laparoscopic examination provides a
panoramic view of the pelvis and allows the surgeon to directly examine the degree of the
pathology and note the presence of any conditions that might contraindicate vaginal
hysterectomy.
The laparoscope can prove a valuable tool for reassessing the severity of the disease
process. Several investigators use a laparoscopic scoring system9,13 determine
numerically the severity of the disease based on uterine size, adnexal accessibility, and
the presence or absence of adhesions, endometriosis, and other abnormalities. Three
critical variables inherent in this scoring system should be assessed during the
laparoscopic examination: accessibility of the cul-de-sac, severity of adhesions, and
severity of endometriosis.
If the extrauterine pathology is absent or minimal on laparoscopic examination, a vaginal
hysterectomy is indicated. Despite current belief, previous pelvic surgery, including
cesarean section, does not preclude a vaginal hysterectomy unless extensive adhesions
are observed during laparoscopy as limiting accessibility, particularly to the anterior
abdominal wall. Patients with minimal pathology have few or no adhesions, little or no
endometriosis, and an accessible cul-se-sac. If laparoscopic assessment reveals moderate
pathology, including moderate adhesions or endometriosis but an accessible cul-de-sac, it
is necessary to determine whether the impediments can be removed laparoscopically
before proceeding to a vaginal hysterectomy. If severe endometriosis is present and the
cul-de-sac is obliterated by severe adhesions, an abdominal hysterectomy is indicated.
Laparoscopically assisted vaginal hysterectomy has compounded the decision-making
dilemma in recent years. Although ACOG acknowledges that laparoscopically assisted
vaginal hysterectomy is an acceptable alternative to abdominal hysterectomy, many
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surgeons continue to question how much laparoscopic assistance is appropriate before
removing the uterus transvaginally.14 If operative laparoscopy is indicated, it is beneficial
to convert to a vaginal hysterectomy as early as possible in the procedure, for example,
after adhesiolysis. Several studies have suggested that nothing is gained by continuing the
laparoscopic dissection once a vaginal hysterectomy can be performed safely, because it
does little more than prolong surgery, increase costs, and increase the risk of morbidity.
Although laparoscopic surgeons have proposed laparoscopically assisted vaginal
hysterectomy as a replacement for abdominal and vaginal hysterectomy, its advantages
over vaginal hysterectomy have not been documented in this population when there are
no contraindications to the vaginal approach.15
Conclusion
If the goal of gynecologic surgeons is to select the optimal route of hysterectomy based
on the best medical outcomes, the clinical factors that are valid indicators of the route to
be selected must be identified. Medical standards in today’s managed care environment
rely on evidence-based practice guidelines that are defined by outcomes rather than
subjective criteria, such as physician comfort, preference, or experience. The marked
variation in health care for alternative hysterectomy procedures will likely persist until
organizations such as the National Institute of Clinical Practice in the United Kingdom,
RCOG and ACOG address the issue of best practice standards and make appropriate
recommendations.16 Gynecologic surgeons can no longer continue to select the route of
hysterectomy on their training or expertise and preference. The adoption of evidencebased practice guidelines offer the best route of hysterectomy to be chosen as each step of
the algorithm requires an evidence demanding question that needs an appropriate answer
before selecting the route of hysterectomy. This removes the possible inappropriate
selection of a particular route of hysterectomy based upon a surgeon’s lack of expertise
and preference
Gynecologic Surgeons must clearly demonstrate that the route of hysterectomy they
choose not only benefits the patient medically but also represents a wise use of health
care dollars. There is no question that abdominal hysterectomy should be performed in
cases of documented serious disease; however, this route should not be misused as now is
prevalent. Developing clinical guidelines based on accurate physical findings is the first
step in ensuring that women will undergo the most appropriate route of hysterectomy that
is cost-effective and meets the standard of quality care.6,17,18 The potential impact of the
physician’s decision to select the vaginal approach may be enormous in terms of
decreased hospital stay, lower hospital charges, and reduced complications.
Physician accountability is at stake. Increasingly as become more knowledgeable there
are demanding hysterectomies be performed vaginally. No woman prefers the discomfort
of an abdominal incision and as more women become aware of their options offered by
the hysterectomy guidelines, they will surely question whether their physician is
influenced by his training, preference and sometimes his lack of experience in offering
the best surgical options, thus informed consent will be a further issue. Without adequate
documentation and fair presentation of the scientific evidence, a truly informed consent
cannot be obtained.
Current practice standards shortchange the physician as well as the patients. Insurers
typically pay more for abdominal hysterectomies based on the assumption that these
patients have more serious pathology when, in fact, they are often performed for the same
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indications. Vaginal hysterectomy patients, on the other hand, are typically discharged
from the hospital in 1 day rather than the typical 3 days permitted abdominal
hysterectomy patients regardless of the pathologic indications.
As gynecologic surgeons our responsibility is to provide the best surgical care proven by
rigorous review of the evidence. We must decide whether we are prepared to offer and
deliver this type of care. The future surgical relationships with our patients will depend
whether we make our surgical decisions based on evidence or because of our lack of
surgical expertise. The choice is ours to make.
References
1. Diker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal
and vaginal hysterectomy among women of reproductive age in the United
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2. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet
Gynecol 1995;85:18-23.
3. Richardson RE, Bournas N, Magos A. Is laparoscopic hysterectomy a
waste of time? Lancet. 1995;345:36-41
4. Querleu D, Cosson M, Paramentier D, Debodinance P. The impact of
laparoscopic surgery on vaginal hysterectomy. Gynecol Endosc.
1993;2:89-91.
5. National Guideline Clearinghouse. Guideline synthesis: Guidelines for
determining the route of hysterectomy for benign conditions. In: National
Guidelines Clearinghouse (NGC) website. Rockville (MD);[cited 2000
Mar 1] http://www.guidelines.gov.
6. Kovac SR. Decision-directed hysterectomy: a possible approach to
improve medical and economic outcomes. Int. J. Gynaecol Obstet.
2000;71(2):159-69.
7. Quality assurance in obstetrics and gynecology. Washington, DC.
American College of Obstetrician and Gynecologists, 1989.
8. National Center for Health Statistics. National Hospital Discharge
Summery, 1997. Public use data filed and documented on CD-ROM.
9 KovacSR, Cruikshank SH, Retto HF:Laparoscopy-assisted vaginal
Hysterectomy. J Gynecol Surg 1990;6:185-93.
10 Kovac SR, Cruikshank SH: Guidelines to determine the route of
oophorectomy
with Hysterectomy. Am J Obstet Gynecol. 1996;185:1483-8.
11 Kovac SR, Abdominal versus vagianl hysterectomy: A statistical Model
for
Determining Physician Decision Making and Patient Outcome. Medical Decision
Making. 1991;11:19-28
12 American College of Obstetricians and Gynecologists. Precis IV: An
Update in Obstetrics and Gynecology. Washington, DC: The
College;1990:page 197.
13 Kung F, Chang S. The relationship between ultrasinic volume and actual
weight of pathologic uterus. Gynecol Obster Invest. 1996;42:35-38.
14 American College of Obstetricians and Gynecologists. Operative
laparoscopy. ACOG EducationalBulletin..Number 239, August 1997.
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15 Kovac SR. Guidelines to determine the role of laparoscopy assisted
vaginal hysterectomy. Am J Obstet Gynecol 1998;178:1257-63.
16 Davies A, Magos A. The hysterectomy lottery. J Obstet Gynaecol
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17 Kovac SR. Hysterectomy outcomes in Patients with Similar Indications.
Obstet Gynecol 2000;95:787-93.
18 Kovac SR: Guidelines to determine the route of hysterectomy. Obstet
Gynecol 1995;85:18-23
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Figure 2.
Figure 3
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