Table 12.3Hysterectomy for treatment of HMB – non-comparative studies

Bibliographic informationStudy type and evidence levelAim of studyNo. of patientsPopulation characteristicsOutcomesResultsSource of funding and additional comments
Clarke 2005364Cohort

EL = 3
Hysterectomy; TCRE5294 of 15280 in hysterectomy group and 4032 of 11478 in the TCR group responded to 5 year follow-upWomen; underwent hysterectomy or TCRE; Surgery for DUB

Part of VALUE/MISTLETOE cohorts

Country: UK
Readmission rates to hospitalReadmission rates by 5 years:

Any type of readmission – 2754 (44.6%) of TCRE, 3477 (41.7%) of hysterectomy. Hazard ratio = 0.87 [CI 0.80 to 0.95], P = 0.038

Gynaecological readmission – TCRE = 837, hysterectomy = 440. Hazard ratio = 0.40 [CI 0.33 to 0.48], P < 0.0001

Operation-related readmission – TCRE = 1026, Hysterectomy = 721. Hazard ratio = 0.53 [CI 0.45 to 0.61], P < 0.001.
Funding source: Department of Health, UK

Study summary: Differences in readmission patterns for hysterectomy and ablation. Women undergoing hysterectomy are less likely to be readmitted to hospital.
Cravello 1999463case series

EL = 3
hysteroscopic myomectomy196 women undergoing hysteroscopic myomectomyhaemorrhagic submucous fibroids

Country: France
Failure rate

(women who underwent hysterectomy after the resection, or with recurrent/uncontrolled haemorrhagic symptoms

Success rate

(complete absence of symptoms, no repeat surgical procedures, taking HRT)
Death: 1 due to malignant lymphoma

Failure: 18% (13% subsequent hysterectomy, 5% recurrent bleeding)

Satisfaction: 68%

13% loss to follow-up
Funding source: not stated

Study summary: Hysteroscopic myomectomy appears to be satisfactory over the long term with low complication rates
De Meeus 1997590retrospective study

EL = 3
AH and VH171 women undergoing hysterectomy

109 (60.4%) VH

62 (39.6%) AH

146 (85.4%) menometrorrhagia

19 (11%) chronic pelvic pain

6 (3.5%) ovarian tumour
VH:

Mean age: 45 years
Mean parity: 1.95
5.5%menopausal
63% previous surgery
10% previous laparoscopy

AH:

Mean age: 47years
Mean parity: 1.59
6.5% menopausal
40% previous surgery
5% previous laparoscopy

Country: France
Uterine weight

Intra-operative events
Uterine weight:

Mean weight: VH: 236 ± 137 g, H: 608 ± 432 g (P < 0.0001)

Weight > 280 g: VH: 32%, H: 77% (P < 0.01)

weight+myomas: VH: 267 g, AH: 879 g (P < 0.0001)

Intra-operative events:

Bleeding (mean vol.): VH: 140± 119 ml, AH: 384 ± 283 ml (P < 0.0001)

Duration of procedure: VH: 50.6±16 min, AH: 90 ± 34.4min (P < 0.0001)

Hospital stay: VH: 6 ± 1.6 days, AH: 8 ± 2.3 days (P < 0.0001)

Bladder injury: VH: 1, AH: 1 (NS)

Conversion to abdominal route: VH: 1
Funding source: Not stated

Study summary: Uterine volume limits VH.

Duration of procedure, blood loss and recovery time lower in VH than AH group
Erian 2005591case series, prospective

EL = 3
laparoscopic subtotal hysterectomy with Plasma Kinetic (PK) and Lap Loop system100 women undergoing laparoscopic subtotal hysterectomy for menorrhagiaMean age: 44.6 years (28–56)

Mean parity: 2 (0–4)

Mean BMI: 26.8 (20–42)

64 had previous abdominal/pelvic surgery

Concomitant surgery:

39 oophorectomy
7 pelvic adhesiolysis
2 excision of implants
2 ovarian cyctectomy
1 cystoscopy

59% of laparoscopic subtotal hysterectomy performed on an outpatient basis

Country: UK
Post-op complications

Operating time

Hospital stay

satisfaction
Post-op complications:

Mean blood loss: 114 ml (20–600)
2 haemorrhage requiring blood transfusion
0 bowel injury
0 bladder injury
0 ureteric injury
0 unintended laparotomy
0 haematoma
0 thrombosis
0 anaesthetic complications

Operating time: 45.5 min (15–90)

Hospital stay: median 3 days (2–5)

Satisfaction: 100% satisfaction with operation and would recommend to friends
Funding source: not stated

Study summary: Laparoscopic subtotal hysterectomy for menorrhagia using the PK and Lap loop system is safe and can be performed as an outpatient procedure, reduced operating time and high patient satisfaction
Gath 1982106Cohort; prospective

EL = 3
hysterectomy174 invited: 18 refused, 156 entered study.women; menorrhagiabenign origin; scheduled for hysterectomy

Country: UK
psychiatric state – present state examination (PSE); Eysenck Personality inventory; Profile of Mood States.Baseline PSE: 1–4 = 66 (42.3%), 5a = 37 (23.7%), 5b = 22 (14.1%), 6–8 = 31 (19.9%). (5 or > = case).

Patients had higher PSE scores than general population (P < 0.001).

Patients vs general population:

Worry = 45% vs 89% (P < 0.001), Somatic features of depression = 9% vs 85% (P < 0.001), tension = 33% vs 77% (P < 0.001), irritability = 17% vs 62% (P < 0.001), situational anxiety = 28% vs 55% (P < 0.001), lack of energy = 8% vs 53% (P < 0.001), simple depression = 16% vs 47% (P < 0.001), social unease = 23% vs 43% (P < 0.001), anxiety = 6% vs 40% (P < 0.001), loss of concentration = 12% vs 31% (P < 0.001).

Patients after vs patients before surgery (P values for after surgery figures vs general population figures:

Worry = 61% vs 89% (P < 0.01), Somatic features of depression = 37% vs 85%, (P < 0.001), tension = 64% vs 77% (P < 0.001); irritability = 22% vs 62% (NS), situational anxiety = 48% vs 55% (P < 0.001), lack of energy = 27% vs 53% (P < 0.001), simple depression = 24% vs 47% (NS), social unease = 28% vs 43% (NS), anxiety = 22% vs 40% (P < 0.001), loss of concentration = 22% vs 31% (P < 0.05).
Funding source: Not stated

Study summary: Hysterectomy reduces level of psychiatric morbidity. Hysterectomy did not cause psychiatric morbidity. Psychiatric morbidity higher in patient group than general population.
Gath 1995592case series (last of a series of 3 studies by the same authors)

EL = 3
hysterectomy239 women undergoing hysterectomy for menorrhagia of benign originStudy 1 – mean age: 42 years
Study 2 – mean age: 38 years
Study 3 – mean age: 39 years

Country: UK
Levels of psychiatric morbidity

Association between psychiatric morbidity and

demographic factors

psychotropic medication

past psychiatric illness

women's understanding and expectation of the operation
Levels of psychiatric morbidity@

Pre-op level of PSE drop: Study 1: 58%, Study 2: 28%, Study 3: 9% (P < 0.001)

Post-op level of PSE drop: Study 1:26%, Study 2: 7%, Study 3: 4% (P < 0.001)

Demographic factors:

Study 1 women sig older than women in Study 2 and 3.

No significant differences between the 3 groups in social class, marital status and menstrual symptoms

Medication:

Anti-menorrhagic drugs: prescribed more frequently in Study 3 than in Study 1 and 2 (P < 0.001)

Psychotropic medication: prescribed more frequently in Study 1 than in Study 2 and 3 (P < 0.001)

Past psychiatric illness: significant fall in ‘neuroticism’ across the 3 studies (P < 0.001)

Women's understanding and expectation of the operation:

Satisfaction with GP's explanation: Study 1: 65%, Study 3: 49% NS

Satisfaction with gynaecologists' explanation: Study 1: 64%, Study 3: 60% NS

Books and magazines as source of information for women: Study 1: 51%, Study 3: 42% NS

Limited information in 10% of women in Study 1 and Study 3.

Women expressing concern about side effects of hysterectomy: Study 1: 56%, Study 3:41% NS
Funding source: MRC

Study summary: Clinicians may have changed referral practice for emotional symptoms, less inclined to refer women with psychological problems for hysterectomy. GP treating more women with explanation and reassurance
Harkki-Siren 1997593Survey

EL = 3
Laparoscopic hysterectomy1165Women; Undergone laparoscopic hysterectomy.

Age = 45.3
BMI = 24.2
Weight of uterus = 185

Indication for surgery:

Uterine fibroids = 627
Menorrhagia = 319
Dysmenorrhoea = 96
Endometriosis = 22
Other = 101

Country: Finland
Duration of operation (min); Estimated blood loss (ml); Hospital stay; Recovery time; ComplicationsDuration of operation (min): 132

Estimated blood loss (ml): 295

Hospital stay: 3.3

Recovery time (days): 17.9

Complications:

Bleeding = 14 (1.2%)
Urinary tract = 32 (2.7%)
Bowel = 5 (0.4%)
Infections = 65 (5.6%)
Other = 3 (0.3%)

Additional surgery:

Blood transfusion = 44 (3.8%)
Laparotomy = 47
Laparoscopy = 6
Vaginal surgery = 14
Ureteral stenting = 2
Funding source: Not stated

Study summary: Laparoscopic hysterectomy offers a short hospital stay and convalescence time to the patient, but effective teaching is imperative to minimize, in particular, the risk of urinary tract injuries.
Hur 1995594Case series

EL = 3
LAVH

Concomitant procedures:

67 appendicectomy

64 posterior repair

39 adhesiolysis

40 SO

10 vaporisation of endometriosis

1 salpingectomy
176Women undergoing LAVH

Mean age: 40.3 years (27–59)

Indications:

139 myoma
11 dysmenorrhoea
7 PID
6 DUB
11 cancer/tumour
2 TV abscess

Country: Korea
Operating time

duration of operation

recovery period

post-op hgb

intra and post-op complications
Mean operating time: 110 min (55–380)

Duration of operation: 4–7 days

Mean recovery period: 3 weeks

Mean post-op Hgb: 1.2 g/dl

Intra-op complications:

1 bladder perforation
1 massive haemorrhage, requiring 3 units of blood transfusion
1 inferior epigastric injury

Post-op complications:

7 (infection, high fever, perineal palsy, voiding problems, vaginal vault bleeding, incsional hernia, pelvic abscess)
Funding source: Not stated

Study summary: LAVH can be safely performed by well-trained laparoscopists with reduced surgical morbidity, blood loss, post-op discomfort, recovery time and hospitalisation
Hurskainen 2004483randomised

EL = 3
LNG-IUS; hysterectomy236 – 119 (116 available at 12 months) to LNG-IUS, 117 (112 available at 12 months) to hysterectomywomen; menstruating; subjective menorrhagia; aged 35 to 49; completed families; Excluded if – submucous fibroids, endometrial polyps, urinary or bowel symptoms due to large fibroid, or ovarian pathology.

Country: Finland
Predictors of outcomeNeither presence of fibroids nor age were predictors of outcome at 12 months for LNG-IUS or hysterectomy.

Multiple regression analysis showed that MBL was the most significant factor predicting outcome.

Comparison of women with and without objective menorrhagia (> 80 ml MBL).

For women in LNG-IUS group women without menorrhagia had better QoL outcomes than women with menorrhagia on: anxiety (P =0.04), EQ-5D (P = 0.05). In the hysterectomy group, women without menorrhagia had better outcomes than those with menorrhagia on: anxiety (P = 0.007), emotional well-being (P = 0.01) and energy (P = 0.0002).

Women without menorrhagia had better outcomes with LNG-IUS than women with menorrhagia on EQ-5D (P = 0.03).

Women with menorrhagia had better outcomes with hysterectomy than LNG-OUS for: anxiety (P = 0.003), general health (P = 0.04), energy (P = 0.05), and pain relief (P = 0.04).
Funding source: Not stated

Study summary: Success or failure of treatment of menorrhagia is multi-factorial, so difficult to predict in individual cases.
Johns 1994595case series

EL = 3
LAVH119 women undergoing LAVH

82 concomitant oophorectomy
Mean age: 39.2 ± 0.7years
Parity: 1.7 ± 0.1

Previous abdominal operations: 0.9 ± 0.1

Indications:

67 pelvic pain
40 DUB
34 pelvic mass
11 myoma
9 cervical dysplasia
8 pelvic relaxation
8 endometriosis
3 adenomyosis
3 pelvic adhesion/pressure

Country: USA
Operation time

blood loss

length of hospital stay

Intra- and post-op complications

Association between experience of LAVH and blood loss and hospital stay
Mean operation time: 79 ± 3 min

Mean blood loss: 135 ± 10 ml (25–500)

Mean length of hospital stay: 59 hours (1–5 days)

Intra- and post-op complications:

1 bladder laceration
1 elective bladder entry to resect endometriosis
4 others (voiding problems, sinus infection, upper resp infection)

Significant association between experience of LAVH and blood loss (P < 0.01) and hospital stay (P < 0.001)

Association between operating time and blood loss: NS

Association between no of previous operations and operating time blood loss or length of hospitalisation: NS
Funding source: not stated

Study summary: The potential advantages of LAVH were suggested
Kjerulff 2000526Prospective case series study,

EL = 3
hysterectomy 30% had concomitant surgery fro urinary incontinence1299Women undergoing hysterectomy for benign conditions, enrolled in the Maryland Women's Health Study 1992–1993 (28 hospitals)

Age range: < 30–70+ years
Parity: 0–3+

Diagnosis:

48% uterine leiomyomas
17% menstrual disorders
13% prolapse
9% endometriosis
3% cancer
3% adnexal condition
2% infectious condition

Country: USA
In-hospital complications

Symptoms relief (vaginal bleeding, pelvic pain, back pain, activity limitation, sleep disturbance, fatigue, abdominal bloating, urinary incontinence)

Psychological functions (depressed, anxious) and limitations in QoL (physical, social functions, poor health perception)

Problems relieved and new problems

Predictors of lack of symptom relief
In-hospital complications:

21% had no complications
67% had ≥ 1 mild complications
11% had ≥ 1 moderate complications
0.7% had ≥ 1 serious complications

4% readmission related to hysterectomy during 1st year, 5% in 2nd year (common reasons: infection, adhesions, intestinal blockage and UTI)

Symptoms relief:

Mean no of symptoms at problematic-severe levels (adjusted):

4.0 pre-op
0.9 at 2 years post-op (P < 0.001)

8% women had same no of symptoms at problematic-severe levels post-hysterectomy as before

Psychological functions and limitations in QoL:

Significant improvement post-op (P < 0.001)
73% depression relieved
68% anxiety relieved
89% no longer reported limited social function

Predictors of lack of symptom relief by logistic regression:

Baseline depression and therapy sig associated with poor outcomes (OR 3.46, 95%CI 1.84 to 6.51)

BSO sig. associated with symptom relief at 2 year (OR 2.01, 95%CI 1.14 to 3.53), but not at 1 year (OR 1.48, 95%CI 0.82 to 2.75)

Household income of ≤ $35,000 sig. associated with lack of symptom relief (OR 0.37, 95% CI 0.24 to 0.59) at 2 years
Funding source: Agency of Health Care Policy and Research, USA

Study summary: Significant improvement after hysterectomy for symptoms relief, psychological function and quality of life up to 2 years post-op. Hysterectomy did not relieve symptoms for those in therapy at time of operation and those who had low incomes
Malzoni 2004596Case series; retrospective

EL = 3
LAVH1020 (series 1 = 396, series 2 = 624)Women; symptomatic myomas or uterine fibroatosis; not suitable for vaginal hysterectomy.

Baseline (Series 1, Series 2):

Age: 50.1, 49.8
BMI: 25.2, 24.8

Indication:

Uterine size > 12 weeks: 171, 398

Adnexal pathologies: 43, 61
History of chronic pelvic pain: 34, 55
Endometriosis: 71, 111
Limited vaginal access: 6 vs 9
Previous laparotomy: 58, 96
Previous laparoscopy: 42, 68

Country: Italy
Operating time (min); Hospital stay (days); Recovery time (days); complications; Postoperative haemoglobin drop (g/dl)Series 1 (1997 to 1999) vs series 2 (2000 to 2002):

Operating time (min): 105 vs 80

Hospital stay (days): 2.4 vs 2.3

Recovery time (days): 19 vs 20

Postoperative haemoglobin drop (g/dl): 1.44 vs 1.39

Complications:

Bowel injury – 0 vs 1
Bladder rupture – 5 vs 1
Ureteral injury – 2 vs 0
Vascular damage – 1 vs 1
Febrile morbidity from infection – 22 vs 32
Vaginal cuff haematoma – 2 vs 0
Vault prolapse – 4 vs 0
Vaginal cuff granulation – 4 vs 3
Hernia complication – 0 vs 0
Re-operation: 2 vs 1

Blood transfusions: 2 vs 1
Funding source: Not stated

Study summary: Laparoscopic hysterectomy is a safe, effective, and reproducible technique after completion of a period of training necessary to standardize the procedure. The results support the importance of optimizing some steps of the surgical technique to reduce severe complications.
Maresh 2002523Clinical audit of a group of hysterectomy cases in a multicentre cohort study

EL = 3
Hysterectomy37048 cases of hysterectomyMedian age: 45 years (12–91) (70% < 50 years)

46% had dysfunctional uterine bleeding with no gynae pathology

67% treated by AH

Indications:

46% DUB (7% fibroids)
35% fibroids (12% clinically relevant)
4% previous treatment with endometrial resection/ablation

Country: UK
Length of stay (LOS)

deaths

Peri-operative complications
LOS:

Median 5 days (1–205, mode 5 days)

AH: mode 5 days
VH: mode 4 days
LH: mode 3 days

Deaths:

14 deaths (8 AH; 6 VH; 0 LH) reported 6 weeks post-op (Mortality rate 0.38/1000, 95% CI 0.25 to 0.64)

Median age at death: 58 years

Peri-operative complications:

Respiratory/CVS complications@

Significantly less risk with VH (Age adjusted – OR 0.51, 95% CI 0.33 to 0.79)

Significantly less bleeding with VH in older women (age dichotomised to ≥ 50 years)

Significantly higher rate of complications with LH vs AH and VH (visceral damage, haemorrhage, return to theatre) (crude OR 1.75, 95% CI 1.36 to 2.24)

Bladder damage : 0.5–0.6% for all methods
Funding source: DH BUPA Foundation
McPherson 2005380Cohort

EL = 3
TCRE; hysterectomy with or without BSONumbers responding at 5 year follow-up: TCRE = 3845, hysterectomy = 339 7, hysterectomy and BSO = 2305Women; undergone TCRE or hysterectomy.

Average age at 5 year follow-up:

TCRE= 47.9, hysterectomy = 54.1, BSO = 50.6

Country: UK
Libido loss, difficult sexual arousal; vaginal dryness.Adjusted OR for loss of libido against TCRE (adjusted for age and HRT use):

Some – Hysterectomy = 1.25 (1.13 to 1.39), BSO = 1.32 (1.16 to 1.51), P = 0.254
Severe – Hysterectomy = 1.29 (1.16 to 1.44), BSO = 1.68 (1.48 to 1.92), P < 0.001
Extreme – hysterectomy = 1.42 (1.22 to 1.65), BSO = 1.80 (1.51 to 2.14), P < 0.001

Adjusted OR for difficulty of sexual arousal against TCRE (adjusted for age and HRT use):

Some – Hysterectomy = 1.16 (1.05 to 1.29), BSO = 1.27 (1.11 to 1.44), P = 0.068
Severe – Hysterectomy = 1.28 (1.15 to 1.44), BSO = 1.79 (1.56 to 2.05), P < 0.001
Extreme – hysterectomy = 1.35 (1.15 to 1.58), BSO = 1.82 (1.52 to 2.19), P < 0.001.

Adjusted OR for vaginal dryness against TCRE (adjusted for age and HRT use):

Some – Hysterectomy = 1.28 (1.15 to 1.41), BSO = 1.17 (1.03 to 1.33), P = 0.057
Severe – Hysterectomy = 1.55 (1.36 to 1.78), BSO = 1.43 (1.22 to 1.69), P = 0.170
Extreme – hysterectomy = 1.50 (1.19 to 1.88), BSO = 1.69 (1.29 to 2.22), P = 0.195.
Funding source: Department of Health and BUPA foundation

Study summary: At 5 years follow up women who had undergone hysterectomy reported increase psychosexual problems than those who had undergone TCRE, and these figures were higher for women who had had BSO at the time of hysterectomy.
McPherson 2004522Case series

EL = 3
Women undergoing abdominal hysterectomy (67% AH, 30% VH, 3% LAVH) 72% received antibiotic prophylactic

58% carried by consultants

Hysterectomies by non-consultants (34% supervised)

< 2% by un-supervised SHO

152/194 consultants performed LHs

11% LH by non-consultants (65% unsupervised, 3% supervised)
37295 cases of hysterectomiesMedian age: 45 years (12–95)

46% DUB
19% fibroids
19% prolapse
5% endometriosis/adenomyosis
3% pelvic mass
8% misc

Country: UK
Peri- and post-op complications, association between these complications and age, comorbidity, indications, pre-op use of antibiotics, grade of surgeon, grade of supervisors and types of hysterectomy14 deaths (0.38/1000) (No death in LH group)

Operative complications in:

3% overall

Age:

20–39 (NS)
40–49 (Reference category)
50 – ≥ 60 (NS)

Operator:

Consultants vs non-consultants (NS)

Supervisor:

Non-supervised vs consultant (Adjusted OR 1.27, 95% CI 1.06 to 1.52)
Non-supervised vs non-consultant (NS)

Indications:

DUB (Reference category)
Fibroids (4.4% vs 3.6%, adjusted OR 1.34, 95%CI 1.14 to 1.56)
Endometriosis/prolapse, pelvic mass and others (NS)

History of serious illness:

No (ref category)
Yes (4.8% vs 3.4%, adjusted OR 1.47, 95%CI 1.18 to 1.82)

Method:

AH (ref category)
VH (NS)
LAVH (6.1% vs 3.6%, adjusted OR 1.92, 95%CI 1.48 to 2.50)

Reduction in risk associated with increasing age in women with fibroids but not DUB

Post-op complications:

1% overall

Age:

20–39 (NS)
40–49 (Reference category)
50 – ≥ 60 (NS)

Operator:

Consultants vs non-consultants (NS)

Supervisor:

Non-supervised vs consultant (NS)
Non-supervised vs non-consultant (NS)

Indications:

DUB (Reference category)
Fibroids (1.2% vs 1.0%, adjusted OR 1.34, 95%CI 1.10 to 1.95)
Endometriosis/prolapse, pelvic mass and others (NS)

History of serious illness:

No (ref category)
Yes (NS)

Method:

AH (ref category)
VH (1.2% vs 0.9%, adjusted OR 1.39, 95% CI 1.01 to 1.90)
LAVH (1.7% vs 0.9%, adjusted OR 1.92, 95%CI 1.00 to 2.68)

Prophylactic antibiotics:

No (ref category)
Yes (NS)

Operative complications:

No (ref category)
Yes (adjusted OR 8.39, 95% CI 6.53 to 10.77)
Funding source: DOH

BUPA

Study summary: Younger women, with more vascular pelvises, undergoing hysterectomy, especially LAVH for fibroids, are at most risk of experiencing severe peri-and post-operative complications. A less invasive approach for fibroids for this group will be beneficial. A less invasive approach for DUB needs further evaluation
McPherson 2005381Prospective cohort

EL = 3
TCRE; Hysterectomy11323 (5592 with TCRE, 5731 with hysterectomy – 1240 vaginal, 4227 abdominal, 251 LAVH)Women; undergone hysterectomy or TCRE for DUB.

Mean average age: TCRE = 42.17, Hysterectomy = 42.21

Presence of fibroids: TCRE = 924 of 3740 (24.71%), hysterectomy = 424 (7.44%) of 5701

Country: UK
Risk of urinary incontinenceOR of Urinary symptoms for hysterectomy compared with TCRE (adjusted for age, BMI, number of pregnancies, caesarean sections, fibroids, co-morbidities, age of first pregnancy):

Urinary incontinence – mild: OR = 1.28 (1.12 to 1.45)
Urinary incontinence – severe: OR = 1.54 (1.29 to 1.85)
Urinary frequency – mild: OR = 1.17 (1.04 to 1.33)
Urinary frequency – severe: OR = 1.36 (1.14 to 1.62)
Nocturia – mild: OR 1.23 (1.04 to 1.46)
Nocturia – severe: OR 1.28 (1.09 to 1.50)

Vaginal:

Urinary incontinence – mild: OR = 1.19 (1.00 to 1.41)
Urinary incontinence – severe: OR = 1.52 (1.20 to 1.93)
Urinary frequency – mild: OR = 1.28 (1.08 to 1.52)
Urinary frequency – severe: OR = 1.51 (1.20 to 1.90)
Nocturia – mild: OR 1.34 (1.06 to 1.69)
Nocturia – severe: OR 1.33 (1.08 to 1.64)

Abdominal:

Urinary incontinence – mild: OR = 1.30 (1.15 to 1.46)
Urinary incontinence – severe: OR = 1.59 (1.34 to 1.89)
Urinary frequency – mild: OR = 1.10 (0.97 to 1.23)
Urinary frequency – severe: OR = 1.15 (.96 to 1.37)
Nocturia – mild: OR 1.19 (1.01 to 1.39)
Nocturia – severe: OR 1.17 (1.00 to 1.36)

LAVH:

Urinary incontinence – mild: OR = 1.82 (1.28 to 2.59)
Urinary incontinence – severe: OR = 2.02 (1.32 to 3.07)
Urinary frequency – mild: OR = 1.03 (0.74 to 1.43)
Urinary frequency – severe: OR = 1.33 (0.85 to 2.07)
Nocturia – mild: OR 1.03 (0.68 to 1.57)
Nocturia – severe: OR 0.90 (0.57 to 1.41)
Funding source: DoH and BUPA
Nathorst-Boos 1992486Survey

EL = 3
Hysterectomy678Women; aged < 55; Hysterectomy for benign conditions.

Indication:

Leiomyoma = 78.9% Endometriosis = 10.8%

Symptoms (% before-after surgery):
HMB = 67.5 vs 0
Dysmenorrhoea = 43.8 vs 2.2
Pressure = 41.8 vs 6.2
Frequent nocturia = 28.4 vs 2.4
Pain = 17.4 vs 1.8
Dyspareunia = 15.2 vs 3.4
No complaints = 6.8 vs 71.4

Country: Sweden
Patient opinions on positive and negative aspects of hysterectomyAdvantages of hysterectomy:

No bleeding = 53%
No pain or pressure = 21.2%
Feel strong, healthy, fit = 13%
No need for contraceptives = 12%
No social handicaps = 4.8%
No worry about cancer = 4.1%
Better blood count = 3.8%
Better sexual life = 2.9%
Other = 3.5%

Disadvantages:

Hot flushes = 6.1%
Ugly scar = 3.4%
Dry sore mucous membranes = 4.0%
Weight gain = 3.5%
Incontinence = 2.9%
Funding source: Not stated
Panici 2005597case series

EL = 3
minilaparotomy hysterectomy148 women undergoing AH (118 minilaparotomy hysterectomy) for benign gynae disease

Reasons for hysterectomy:

115 (78%) fibroids with HMB
20 (13%) fibroids with adnexal pathology
7 (5%) stress incontinence
6 (4%) DUB
All women:

Median age: 47 years (37–85)
Median BMI: 25 (18–45)
Median parity: 2 (0–4)

27(18%) menopausal women
18 (12%) hypertension
1(1%) diabetes
1 (1%) myastenia

Country: Italy
Operating time

intra- and post-op complications

Post-op stay
Operating time: 50 min (34–88)

0 intra-operative complications

0 needed blood transfusion

16 (14%) minor post-op complications (not specified)

Median bladder drainage: 1 day (1–2)

Median post-op stay: 3 days (2–5)
Funding source: not stated

Study summary: Minilaparotomy hysterectomy is feasible for women undergoing hysterectomy for benign disease because of the excellent outcomes achieved
Parkar 2004598Retrospective case analysis

EL = 3
LAVH149 LAVHWomen undergoing LAVH

86 Menorrhagia
27 dysmenorrhoea
21 intermenstrual bleeding
9 post-coital bleeding
3 asymptomatic fibroids
3 renal changes on IVP
84 previous surgery

Age: 35-> 56 (51% between 46–50 years)

Country: Kenya
Operation time

Hospital stay

Intra- and post-op complications
Operation time: 45–245 min (58% between 91–120 min)

Hospital stay: 2–29 days (95% 2 nights)

Intra-op complications:

5 bladder injury
1 venticular fibrillation
2 bowel injury

Post-op complications:

1 intra-abdominal haemorrhage
2 omental evisceration 1 intestinal obstruction
1 bladder injury (delayed recognition)

Laparotomy conversion:

Intra-op: 5 due to bladder/rectal injury

Post-op: 3 due to bladder tear and bleeding
Funding source: Not stated

Study summary: LAVH gaining popularity
Riza 1997599Case series

EL = 3
LAVH209 (1090 records available for review)Women; LAVH for benign condition

Endometriosis = 52.2%
Leiomyomas = 30.2%
Endometriosis and Leiomyomas = 8.8%
Menorrhagia = 5%
Adenocarcinoma = 1.1%
Squamous = 1.1%
Cancer in situ and menorrhagia = 0.5%
Other = 1.1%

Average age = 41.3
Gravidity = 2.7
Weight (lbs) = 159.6
Uterine weight (g) = 178.6

Country: USA
Operative time; operative blood loss; complications; Length of stayAverage operative time = 117.3 minutes

Post-operative length of stay = 0.7 days

Average intra-operative blood loss = 242.3 ml

Complications: fever = 6, transfusion = 3, UTI = 2, Vaginal cuff cellulitis = 1
Funding source: Not stated
Schofield 1991600retrospective survey by telephone interview and postal questionnaire

EL = 3
Hysterectomy236Women who had had a hysterectomy between 2–10 years ago (50% between 2–5 years, 50% between 6–20 years)

51% hysterectomy only
13% hysterectomy + 1 ovary
36% hysterectomy + BSO

Mean age at time of hysterectomy: 44.2 years (28–68)

Country: Australia
Hysterectomy characteristics

Perceived benefits and problems

Satisfaction with hysterectomy
Hysterectomy characteristics:

Perceived reasons:

50% for bleeding and pain
20% fibroids
16% prolapse
17% endometriosis

Perceived benefits:

57% relief from heavy periods
Overall 66% of all symptoms experienced before hysterectomy have improved
28% no different
59% had symptoms made worse by hysterectomy (22% required visit to GPs and 7% to gynaecologist in previous 12 months)

Satisfaction with hysterectomy:

96% women satisfied
95% would make same decision again
4% said hysterectomy caused more problems
7% would not have agreed to have op

Women with fewer than 3 children significantly more satisfied with their recovery
Women aged < 50 years more likely to be satisfied with hysterectomy outcome
Funding source: NH and MRC Public Health Grant

Study summary: High levels of satisfaction with hysterectomy. Problems after hysterectomy also high enough to warrant consideration for trials of hysterectomy vs conservative treatment
Takamizawa 1999601Case series

EL = 3
Total hysterectomy923Women; undergone hysterectomy for uterine fibroids

Country: Japan
ComplicationsComplications:

Bladder laceration = 5
Ureteric injury = 5
Bowel injury = 2
Haemorrhage requiring transfusion = 41
Pulmonary embolism = 1
Re-operation = 1
Prolonged paralytic ileus = 6
Vaginal vault problem = 7
Abdominal wound dehiscence = 3
Funding source: Not stated

Study summary: The incidences of complications and unrecognized uterine malignancies were similar to the results of previous studies. Of patients undergoing hysterectomy for presumed benign leiomyomas, the risk of major complications was 6.0% (55/923) and the risk of preoperatively undiagnosed uterine malignancies was 0.4%.
Toma 2004602Retrospective chart audit

EL = 3
Hysterectomychart audit of 372 hysterectomiesMean age: 48.5 ± 11.5 years
Mean BMI: 28.6 ± 7.3 (29.6% BMI 25 – 29.9; 36.6% BMI ≥ 30)
Mean Parity: 2.1 ± 1.5
78% AH
14% VH
5.9% LAVH
2.2% VH converted to AH
79.8% total hysterectomies
16.1% subtotal
4% radical/modified radical hysterectomies

Indications:

26.4% abnormal uterine bleeding
16% leiomyomas
11.4% pelvic mass, neoplasm or cyst
11% endometrial/ovarian/cervical cancer
10.6% Chronic dysmenorrhoea
8.9% endometrial hyperplasia, dysplasia or family history of cancer
7.6% pelvic prolapse/incontinence
5.1% endometriosis
2.9% chronic salpingitis, hydro- and pyo-salpinx
16% had diagnosis of cancer pre-op
20% had diagnosis of cancer post-op

Country: Canada
Factors associated with:

length of stay (LOS)

length of surgery

indication for surgery and approach

readmissions

complications

infections

repeat laparotomies

Rate of concurrent oophorectomy
26 visited emergency room within 30 days of discharge

19 readmission

15.3% infections (UTI, wound and pelvic) (significantly higher BMI and longer LOS length of surgery in this group)

4% repeat/unplanned laparotomy

24.5% other complications (11.3% excessive bleeding, 5.4% post-op ileus)

< 2% bladder, bowel, pulmonary function, cardiac function or drug reactions

Removal of both or last ovary:

65% (57% of the 257 pre-menopausal women; 84% of the 113 post-menopausal women).
35% in women with dysfunctional uterine bleeding.
71.4% in women with leiomyomas.

AH vs VH:

Age – NS
BMI – 29.2 (7.8) vs 25.8 (4.6) (P < 0.01)
LOS in days – 5.2 (4.8) vs 3.0 (1.6) (P < 0.01)
Length of surgery in minutes – 106.3 (48.7) vs 84.7 (34.6)
Infection – NS
Readmission – NS
Excessive bleeding or complication – NS

Logistic regression:

Patient 1.1 times more likely to have AH for each one-point increase in BMI (P = 0.003); 47.6 times more likely to have AH if concurrent unilateral/bilateral oophorectomy (P < 0.001); 1.7 times more likely to have VH with each additional child
Funding source: not stated

Study summary: Significant reduction in LOS with the VH when compared with AH
Varol 2001524retrospective review of medical records

EL = 3
VH, AH and LAVH

Prophylactic antibiotics received:

45% AH
84% VH
80% LAVH
1940 women undergoing hysterectomy for benign non-obstetric indications 1986–1995:

462 (24%) VH
1440 (74%) AH
36 (2%) LAVH
VH:

Mean age: 57 years
Mean parity: 3.1
6.5% Leiomyomas
19.5% DUB
0% endometriosis
1.7% adenomyosis
67.3% uterovaginal prolapse
2.6% cervical dysplasia
0% adenal mass
0% PID
0.2% endometrial hyperplasia
0.9% pelvic pain
1.3% others

AH:

Mean age: 45.3 years
Mean parity: 2.5
34% Leiomyomas
26.5% DUB
5.4% endometriosis
11% adenomyosis
0.4% uterovaginal prolapse
4.9% cervical dysplasia
7.6% adenal mass
1.7% PID
4.3% endometrial hyperplasia
2.6% pelvic pain
1.5% others

LAVH:

Mean age: 44.4 years
Mean parity: 1.8
25% leiomyomas
50% DUB
11% endometriosis
0% adenomyosis
2.8% uterovaginal prolapse
0% cervical dysplasia
0% adenal mass
0% PID
0% endometrial hyperplasia
5.6% pelvic pain
5.6% others

Concurrent surgical procedures:

VH:91.5%
84.8% colporrhaphy
2.2% adnexectomy
0% adhesiolysis
1.3% Burch colposupension
0% appendicectomy
0% lipectomy
3.2% other

AH: 65.7%

1.9% colporrhaphy
50.8% adnexectomy
4.5% adhesiolysis
2.3% Burch colposupension
3.7% appendicectomy
Post-op complications and injuries to adjacent organsPost-op complications:

Mortality rate: 1.5/1000 women

VH:

27.3% overall complication rates
10.2% febrile morbidity
9.7% infections
5% haemorrhage requiring transfusion
1% unintended major surgical procedure
0% life-threatening event
2.4% re-hospitalisation
3.4% minor complications (retention, incontinence, ileus etc)
Injuries to adjacent organs (0.5–1.5% bladder, 0.05–0.1% ureter, 0.1–0.8% bowel, 0.1–0.2% vesicovaginal fistula)

AH:

44% overall complication rates
15.9% febrile morbidity
12.6% infections
6.5% haemorrhage requiring transfusion
3% unintended major surgical procedure
0.4% life-threatening event
2% re-hospitalisation
14.4% minor complications (retention, incontinence, ileus etc)
Injuries to adjacent organs (1–2% bladder, 0.1–0.5% ureter, 0.1–0.5% bowel, 0.1 −0.2% vesicovaginal fistula)

LAVH:

22.2% overall complication rates
5.5% febrile morbidity
0% infections
5.5% haemorrhage requiring transfusion
2.8% unintended major surgical procedure
0% life-threatening event
8.3% re-hospitalisation
2.8% minor complications (retention, incontinence, ileus etc)
Injuries to adjacent organs (1.1% bladder, 0.3% ureter, 0.5% bowel, 0.3% vesicovaginal fistula)
Funding source: Victoria Medical Foundation

Study summary: Higher complication in AH than VH
Walker 2006603Cross-sectional survey

EL = 3
UAE258 questionnaires sent out, 172 repliedWomen; undergone UAE

Country: UK
Amenorrhoea/meno pause rate; vaginal discharge; sexual function; subsequent treatment for fibroids; Satisfaction with UAEAmenorrhoea/menopause rate:

Amenorrhoea = 8
Normal flow = 96
Reduced flow but heavier than normal = 32
No change = 4
Heavier = 1
Longer = 3
Reduction only temporary = 32

164 women were pre-menopausal at time of treatment

Vaginal discharge:

83 women complained of vaginal discharge post-treatment.

Sexual function:

Improved = 31
Same = 64
Worse = 12

Subsequent treatment for fibroids:

28 (16%) had further treatment.

Satisfaction with UAE:

Very satisfied = 104
Satisfied = 48
Dissatisfied = 5
Very dissatisfied = 2

Quality of life:

Better = 146
Not improved = 8
Funding source: Not stated

From: Evidence Tables

Cover of Heavy Menstrual Bleeding
Heavy Menstrual Bleeding.
NICE Clinical Guidelines, No. 44.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2007 Jan.
Copyright © 2007, National Collaborating Centre for Women's and Children's Health.

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