Which Hysterectomy in 2010?

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13 Νοε 2013 (πριν από 3 χρόνια και 9 μήνες)

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Which Hysterectomy in 2010?

A user’s guide to everything CHOICE
magazine doesn’t tell you.

Philip Thomas FRANZCOG FRCS

1

Overview


Second commonest major abdominal
procedure after LUSCS


Approx 20,000 per year in Aust


Incidence is decreasing despite population growth


Medical alternatives/ablative treatments


Abdominal hysterectomy still by far the most
common

2

Medicare data
-

route of hysterectomy

(*no specific item number for TLH)


2000
-
01

2008
-
09

Abdominal

8498(50%)

5919(38%)

Vaginal

6015(35%)

5558(36%)

All “laparoscopic” *

2477(15%)

3901(26%)

TOTAL

16990

15378

3

(Molloy, D, O&G 2010, 12:1, 30
-
31)

USA data


600,000/yr. By age 65, 33% will have had a hysterectomy


Route

%

Abdominal

66%

Vaginal

22%

Laparoscopic

12%

4

(Journal ACOG, Oct 2009)

So how did it all start?


History of the hysterectomy


First vaginal hysterectomy



500 BC, Hippocrates
-

procidentia


1600, Schenk, first series of 26 cases


1813, Langenbeck. Uterine cancer


First “modern” VH by Heaney, 1846


Aunt had succumbed earlier from a VH


5

Hystory of the hyster (2)


First abdominal hysterectomy


Langenbeck, 1825


7 minutes operative time


Patient died several hours later


Heath (Manchester) first to ligate uterine arteries


First modern TAH, 1878, Freund, Germany


Anaesthesia, antisepsis, Trendelenberg, vessel ligation

6

Hystory of the Hyster (3)



First laparoscopic hysterectomies


LAVH, Reich, 1989


TLH, Reich, 1993 (18 years ago!)


First TLH in Australia, Reich, 1994


First series of around 200 cases, Chapron, 1997


Commonplace at RWH Melbourne, approx 2005


7

Reich, H, DeCaprio, J, McGlynn, F. Laparoscopic hysterectomy. J
Gynecol Surg 1989; 5:213.

Questions and answers


Indications for hysterectomy in benign gynae
disease?


Role of the subtotal hysterectomy?


Role of prophylactic oophorectomy?


Different types and terminology


Route of hysterectomy. Why is TLH best?



8

Indications for hysterectomy

Indication

Abdominal

Vaginal

Leiomyomata

40%

17%

Endometriosis

12%

Not reported

Cancer/preinv
asive disease

12.6%

Not reported

Abnormal
bleeding

9.5%

Not reported

Prolapse

3%

44%


Various others


Adenomyosis


PID


Chronic pain


PPH


Cornual ectopics


Sterilisation

Farquar and Steiner Obstet Gynaecol
2002;99:229

9

Quality of life


All aimed at increasing quality of life in a fashion
that is timely and appropriate to the patient
needs, beliefs, sense of self


Use of scarce public and private sector resources


Use of available technology


Appropriate surgeon in terms of current skills,
evolving skills, credentialing, social responsibility
and career direction


… after a full, transparent and evidence based
discussion with the patient


10

Sub total hysterectomy

3 reviews, 733 patients in total


subtotal hysterectomy does
not

offer improved
outcomes for sexual, urinary or bowel function when
compared with total abdominal hysterectomy.


Surgery is shorter and intra
-
operative blood loss and
fever are reduced


women are more likely to experience ongoing cyclical
bleeding up to a year after surgery with subtotal
hysterectomy compared to total hysterectomy


(May still be indicated in context of mesh support for
upper vaginal prolapse/sacrocolpopexy)

Lethaby A, Ivanova V, Johnson N. Total versus subtotal
hysterectomy for benign gynaecological conditions.
Cochrane Database of Systematic Reviews 2006, Issue 2
2.

11

Any remaining indications for STH?


Obliterated pouch of Douglas


Patient choice after counseling re risk of re
bleeding/ need for pap smears etc


Context of CS hyster where cx indistinct


Very short vaginal length?

12

Contraindications


Hyster for cx dysplasia


PCB/IMB/heavy discharge


Known endo hyperplasia or cancer


Patient unwilling/unable to continue Pap
smears

13

Role of prophylactic oophorectomy

Pre
-
menopausal subjects


Perceived risk of ovarian carcinoma


Lifetime risk


Avoidance further gynae procedures


Residual ovary syndrome


Incidence


119 trials, one controlled with 362 pp , no RCT; no
meta
-
analysis possible


evidence of very low quality of a positive effect on
psychological well
-
being for both groups at one year follow
up. No significant differences were found between the
groups of women studied regarding any aspect of their
sexuality.


Orozco LJ, Salazar A, Clarke J, Tristán M. Hysterectomy versus hysterectomy
plus oophorectomy for premenopausal women. Cochrane Database of
Systematic Reviews 2008, Issue 3.

14

Role of prophylactic oophorectomy

Pre
-
menopausal subjects


Chance of residual ovary syndrome about 2
-
3% (personal experience) uncomplicated cases


Therefore number needed to treat is 30


May still be clearer role in those with residual
endometriosis or other adnexal disease.

Orozco LJ, Salazar A, Clarke J, Tristán M. Hysterectomy versus hysterectomy
plus oophorectomy for premenopausal women. Cochrane Database of
Systematic Reviews 2008, Issue 3.

15

Prophylactic oophorectomy (2)


Therefore


Until well designed trials or comparative studies
are published, any prophylactic BSO in a pre
-
menopausal subject should be undertaken with
extreme caution


Post
-

mp different


Adrenal vs.. ovarian androgens


16

Classification of the “Lap hyster”

Richardson RE, Bournas N, Magos AL. Is laparoscopic
hysterectomy a a waste of time? Lancet 1995;345
-
6

17

Stage

Laparoscopic component

0

Dx lap only

1

Lap adhesiolysis or Rx endometriosis

2

One or both adnexae freed
laparoscopically (LAVH)

3

Bladder dissected from uterus
laparoscopically (LAVH)

4

Uterine arteries/ veins transected
laparoscopically

5

Vault opened and closed laparoscopically
(TLH)

So why do a TLH?



Avoids
abdominal

hysterectomy


Where VH not possible


Narrow access, inadequate descent, bulky uterus,
low lying fibroids, adhesions or severe endo


Desire for upper vaginal support with mesh
(LSH)


LAVH (note not uterines and uterosacrals)
does NOT give descent so does not turn an
obligatory AH into a VH

18

So what’s the big deal and what’s the
evidence?


Outcomes of surgery depends on surgeon
expertise/experience and training


Old jungle saying: not all surgeons same


RCT's and comparative studies can eliminate
selection bias but not surgeon experience


No statistical difference does not mean NO
difference and lack of evidence not same as
NO evidence

19

The evidence so far: route of
hysterectomy


Most data so far extremely diverse in
geography, expertise, what operation was
done and cover a time period of rapid surgical
evolution and development of expertise


Adverse outcomes quite rare so large numbers
needed


Single surgeon series much more homogenous
data

20

The evidence (cont)


Cochrane 2006. 27 trials, 3643 patients


No diff between VH and LH in return to normal
activity, complications, conversion to open, LOS


No diffs in infective morbidities,
thromboembolism, sexual dysfunction, pt
satisfaction between all approaches.


VH and LH quicker return to normal cf AH


LH longest operating time, LAVH/AH same, VH
fastest

Johnson, Barlow Letharby et al. Surgical approach to
hysterectomy for benign gynaecological disease. Cochrane
Database Syst Rev 2006

21

The evidence (cont)


Cochrane review (2)


LH less blood loss and wound complications cf AH


Total urinary tract complications (bladder and
ureter) highest in LH


Subsequent development in technique


This now out of date


This data included the eVALuate study (see below)

22

The eVALuate study


Design


Multicentre twin arm randomised trial


AH vs. LH (292 & 584) ; LH vs. VH (168 & 336)


All benign, uterus <12 weeks, no prolapse


Findings


LH took longer to perform than AH or VH


(84 vs. 50, 72 vs. 39 minutes respectively)


LH has less post op pain than AH, shorter LOS (3 vs. 4
days) quicker recovery and better QOL at 6 weeks



Garry R, Fountain J, Mason S et al. The
eVALuate study. BMJ 2004; 328:129

23

The eVALuate study (2)


Findings (cont)


Unexpected pathology was recognised and
treated more frequently in LH group


Limitations


Conversion to laparotomy was counted as major
complication in the LH group*


No standard way of taking pedicles


Surgeon experience prior to commencing as as
little as 15 cases



Chien P, Khan K, Mol BW> How to interpret
the findings of the eVALuate study. BJOG
2005; 112:391.

24

The eVALuate study (3)


Limitations (cont)


Less experience with LH vs. AH, with no
consideration of learning curve*


Results for VH were all favorable but sample size
underpowered to detect diff other than shorter
operating time.

*Wattiez et al. The learning cure of TLH: comparative
analysis of 1647 cases. J Am Assoc Gynecol Laparosc 2002;
9:339

25

Newest developments


Instrumentation


Routine use of vaginal cuffs e.g. Rumi
-
Koh,
McCartney tube


Impact of ureteric injury


Discarding linear staplers in favor newer energy
sources


“Active” bipolar


Harmonic scalpel


MMC open hyster study and findings/applicability to LH

26

Newest developments (2)


Robotic systems (DaVinci, Intuitive Surgical)


Origins


Principles


Stereoscopic vision


Precision/ surgeon fatigue/ dexterity


Zero conversion rate* since changing from
“straight stick” TLH to RLH



Applicability to other procedures


*Thomas Payne, Louisiana. Personal
communication.

27

SO where are we now?


First TLH 1988


Now still only 15% of the market


First lap prostatectomy in 1990’s


Biggest series in 2001 around 20 cases


Now 85% are done this way


First lap chole mid 1980’s


Now 90% of choles are lap


Not open unless special reasons


Despite still higher and plateaued major cx cf open

28

So what’s the problem?

Issue

Lap chole

TLH

Size of organ

Small

Potentially large

Number of vessels

One

four

Suturing required?

No

yes

Training expectation

High

Low*

AGES classification of difficulty of lap surgery
-

recommends only those with specific credentialing
or evidence of preceptorship or other training
embark on level 5or6 laparoscopy

29

Recommendation


Based on the above discussion and evidence:


When you can do a VH, then do it


Esp in the context of prolapse


Other thoughts? See below!


There is little role for “prophylactic” BSO in
premenopausal subjects


Post mp may be different


There is little or no role for STH


Esp in context of upper vaginal support with mesh

30

Recommendation (2)


There is NO role for the straight forward TAH
in 2010


Unless special circumstances exist


?malignancy. Size not important


In cases of difficulty, bring out the robot


There is certainly a learning curve


Easily overcome with time and training, as for lap chole


Newer instruments and “crystallizing” of technique


Specific item numbers for TLH

31

Research directions


Vaginal cuffs


Rumi
-
Koh and McCartney/ barbed sutures


New studies with standardization of technique


Energy sources


PK and Harmonic


Less pain and quicker recovery (MMC study)


Repeat randomization


With all the above, routine thromboprophylaxis,
antibiotics, Harmonic and mx of the vault

32

Quote from Prof Duncan Turner MD


Treasurer ISGE, in Editorial, ISGE Newsletter, May 2010


“In 2010 (in the USA) TLH has only 15% of the market despite
the fact that we believe this to be the the best operation.
Urologists have been forced to learn laparoscopic
prostatectomy (now 85%) by patient demand for a procedure
that has not been shown to be better but has better recovery
and is less painful than traditional surgery. There has been
similar demand for TLH but is has been diminished by those
who tell patients that they are not good candidates, that the
surgery is too difficult, experimental or dangerous. Those
opinions from gynecologists who do not know how to perform
such an operation and for unknown reasons do not refer to
someone who can”

33

Thank You!


34