Which Which Hysterectomy Hysterectomy

in 2010?in 2010?A user’s guide to everything A user’s guide to everything

CHOICE magazine doesn’t tell CHOICE magazine doesn’t tell you.you.

Philip Thomas FRANZCOG FRCSPhilip Thomas FRANZCOG FRCS

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OverviewOverview

Second commonest major abdominal Second commonest major abdominal procedure after LUSCSprocedure after LUSCS Approx 20,000 per year in AustApprox 20,000 per year in Aust Incidence is decreasing despite population Incidence is decreasing despite population

growthgrowth Medical alternatives/ablative treatmentsMedical alternatives/ablative treatments

Abdominal hysterectomy still by far the most Abdominal hysterectomy still by far the most commoncommon

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Medicare data- route of hysterectomyMedicare data- route of hysterectomy(*no specific item number for TLH)(*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

(Molloy, D, O&G 2010, 12:1, 30-31) 3

USA dataUSA data

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

Route %

Abdominal 66%

Vaginal 22%

Laparoscopic 12%

(Journal ACOG, Oct 2009) 4

So how did it all start?So how did it all start?History of the hysterectomyHistory of the hysterectomy

First vaginal hysterectomy First vaginal hysterectomy 500 BC, Hippocrates- procidentia500 BC, Hippocrates- procidentia 1600, Schenk, first series of 26 cases1600, Schenk, first series of 26 cases 1813, Langenbeck. Uterine cancer1813, Langenbeck. Uterine cancer First “modern” VH by Heaney, 1846First “modern” VH by Heaney, 1846

Aunt had succumbed earlier from a VHAunt had succumbed earlier from a VH

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Hystory of the hyster Hystory of the hyster (2)(2)

First abdominal hysterectomyFirst abdominal hysterectomy Langenbeck, 1825Langenbeck, 1825

7 minutes operative time7 minutes operative time Patient died several hours laterPatient died several hours later

Heath (Manchester) first to ligate uterine Heath (Manchester) first to ligate uterine arteriesarteries

First modern TAH, 1878, Freund, GermanyFirst modern TAH, 1878, Freund, Germany Anaesthesia, antisepsis, Trendelenberg, vessel Anaesthesia, antisepsis, Trendelenberg, vessel

ligationligation

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Hystory of the Hyster Hystory of the Hyster (3)(3)

First laparoscopic hysterectomiesFirst laparoscopic hysterectomies LAVH, Reich, 1989LAVH, Reich, 1989 TLH, Reich, 1993 (18 years ago!)TLH, Reich, 1993 (18 years ago!) First TLH in Australia, Reich, 1994First TLH in Australia, Reich, 1994 First series of around 200 cases, Chapron, First series of around 200 cases, Chapron,

19971997 Commonplace at RWH Melbourne, approx Commonplace at RWH Melbourne, approx

20052005

Reich, H, DeCaprio, J, McGlynn, F. Laparoscopic hysterectomy. J Gynecol Surg 1989; 5:213.7

Questions and answersQuestions and answers

Indications for hysterectomy in benign Indications for hysterectomy in benign gynae disease?gynae disease?

Role of the subtotal hysterectomy?Role of the subtotal hysterectomy?

Role of prophylactic oophorectomy?Role of prophylactic oophorectomy?

Different types and terminologyDifferent types and terminology

Route of hysterectomy. Why is TLH best?Route of hysterectomy. Why is TLH best?

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Indications for Indications for hysterectomyhysterectomy

Indication Abdominal Vaginal

Leiomyomata 40% 17%

Endometriosis 12% Not reported

Cancer/preinvasive disease

12.6% Not reported

Abnormal bleeding

9.5% Not reported

Prolapse 3% 44%

Various othersVarious others AdenomyosisAdenomyosis PIDPID Chronic painChronic pain PPHPPH Cornual ectopicsCornual ectopics SterilisationSterilisation

Farquar and Steiner Obstet Gynaecol 2002;99:229

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Quality of lifeQuality of life

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

Use of scarce public and private sector Use of scarce public and private sector resourcesresources

Use of available technologyUse of available technologyAppropriate surgeon in terms of current Appropriate surgeon in terms of current

skills, evolving skills, credentialing, skills, evolving skills, credentialing, social responsibility and career directionsocial responsibility and career direction

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

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Sub total hysterectomySub total hysterectomy3 reviews, 733 patients in total3 reviews, 733 patients in total

subtotal hysterectomy does not offer improved subtotal hysterectomy does not offer improved outcomes for sexual, urinary or bowel function outcomes for sexual, urinary or bowel function when compared with total abdominal when compared with total abdominal hysterectomy. hysterectomy.

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

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

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

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Any remaining Any remaining indications for STH?indications for STH?

Obliterated pouch of DouglasObliterated pouch of Douglas

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

Context of CS hyster where cx indistinctContext of CS hyster where cx indistinct

Very short vaginal length?Very short vaginal length?

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ContraindicationsContraindications

Hyster for cx dysplasiaHyster for cx dysplasia

PCB/IMB/heavy dischargePCB/IMB/heavy discharge

Known endo hyperplasia or cancerKnown endo hyperplasia or cancer

Patient unwilling/unable to continue Pap Patient unwilling/unable to continue Pap smearssmears

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Role of prophylactic Role of prophylactic oophorectomyoophorectomy

Pre-menopausal subjectsPre-menopausal subjects

Perceived risk of ovarian carcinomaPerceived risk of ovarian carcinoma Lifetime riskLifetime risk

Avoidance further gynae proceduresAvoidance further gynae procedures Residual ovary syndromeResidual ovary syndrome IncidenceIncidence

119 trials, one controlled with 362 pp , no 119 trials, one controlled with 362 pp , no RCT; no meta-analysis possibleRCT; no meta-analysis possible evidence of very low quality of a positive evidence of very low quality of a positive

effect on psychological well-being for both effect on psychological well-being for both groups at one year follow up. No significant groups at one year follow up. No significant differences were found between the groups of differences were found between the groups of women studied regarding any aspect of their women studied regarding any aspect of their sexuality.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 Role of prophylactic oophorectomyoophorectomy

Pre-menopausal subjectsPre-menopausal subjects

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

Therefore number needed to treat is 30Therefore number needed to treat is 30

May still be clearer role in those with May still be clearer role in those with residual endometriosis or other adnexal residual endometriosis or other adnexal disease. 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 Prophylactic oophorectomy (2) oophorectomy (2)

ThereforeTherefore Until well designed trials or comparative Until well designed trials or comparative

studies are published, any prophylactic BSO studies are published, any prophylactic BSO in a pre-menopausal subject should be in a pre-menopausal subject should be undertaken with extreme cautionundertaken with extreme caution Post- mp differentPost- mp different Adrenal vs.. ovarian androgensAdrenal vs.. ovarian androgens

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Classification of the “Lap Classification of the “Lap hyster”hyster”

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)

Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterectomy a a waste of time? Lancet 1995;345-617

So why do a TLH?So why do a TLH?

Avoids Avoids abdominalabdominal hysterectomy hysterectomy

Where VH not possibleWhere VH not possible Narrow access, inadequate descent, bulky Narrow access, inadequate descent, bulky

uterus, low lying fibroids, adhesions or severe uterus, low lying fibroids, adhesions or severe endoendo

Desire for upper vaginal support with mesh Desire for upper vaginal support with mesh (LSH)(LSH)

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

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

Outcomes of surgery depends on surgeon Outcomes of surgery depends on surgeon expertise/experience and trainingexpertise/experience and training Old jungle saying: not all surgeons sameOld jungle saying: not all surgeons same

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

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

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The evidence so far: route of The evidence so far: route of hysterectomyhysterectomy

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

Adverse outcomes quite rare so large Adverse outcomes quite rare so large numbers needednumbers needed

Single surgeon series much more Single surgeon series much more homogenous data homogenous data

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The evidence (cont)The evidence (cont)

Cochrane 2006. 27 trials, 3643 patientsCochrane 2006. 27 trials, 3643 patients No diff between VH and LH in return to normal No diff between VH and LH in return to normal

activity, complications, conversion to open, activity, complications, conversion to open, LOSLOS

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

VH and LH quicker return to normal cf AHVH and LH quicker return to normal cf AH LH longest operating time, LAVH/AH same, VH LH longest operating time, LAVH/AH same, VH

fastest fastest

Johnson, Barlow Letharby et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 200621

The evidence (cont)The evidence (cont)

Cochrane review (2)Cochrane review (2) LH less blood loss and wound complications cf LH less blood loss and wound complications cf

AHAH Total urinary tract complications (bladder and Total urinary tract complications (bladder and

ureter) highest in LHureter) highest in LH Subsequent development in techniqueSubsequent development in technique This now out of dateThis now out of date

This data included the eVALuate study (see This data included the eVALuate study (see below) below)

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The eVALuate studyThe eVALuate study

DesignDesign Multicentre twin arm randomised trial Multicentre twin arm randomised trial

AH vs. LH (292 & 584) ; LH vs. VH (168 & 336)AH vs. LH (292 & 584) ; LH vs. VH (168 & 336) All benign, uterus <12 weeks, no prolapseAll benign, uterus <12 weeks, no prolapse

FindingsFindings LH took longer to perform than AH or VHLH took longer to perform than AH or VH

(84 vs. 50, 72 vs. 39 minutes respectively)(84 vs. 50, 72 vs. 39 minutes respectively) LH has less post op pain than AH, shorter LH has less post op pain than AH, shorter

LOS (3 vs. 4 days) quicker recovery and LOS (3 vs. 4 days) quicker recovery and better QOL at 6 weeksbetter QOL at 6 weeks

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

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The eVALuate study The eVALuate study (2)(2)

Findings (cont)Findings (cont) Unexpected pathology was recognised and Unexpected pathology was recognised and

treated more frequently in LH grouptreated more frequently in LH group

LimitationsLimitations Conversion to laparotomy was counted as Conversion to laparotomy was counted as

major complication in the LH group*major complication in the LH group* No standard way of taking pediclesNo standard way of taking pedicles Surgeon experience prior to commencing as Surgeon experience prior to commencing as

as little as 15 casesas little as 15 cases

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

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The eVALuate study The eVALuate study (3)(3)

Limitations (cont)Limitations (cont) Less experience with LH vs. AH, with no Less experience with LH vs. AH, with no

consideration of learning curve*consideration of learning curve* Results for VH were all favorable but sample Results for VH were all favorable but sample

size underpowered to detect diff other than size underpowered to detect diff other than shorter operating time.shorter operating time.

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

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Newest developmentsNewest developments

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

McCartney tubeMcCartney tube Impact of ureteric injuryImpact of ureteric injury Discarding linear staplers in favor newer Discarding linear staplers in favor newer

energy sourcesenergy sources ““Active” bipolarActive” bipolar Harmonic scalpelHarmonic scalpel MMC open hyster study and MMC open hyster study and

findings/applicability to LH findings/applicability to LH

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Newest developments Newest developments (2)(2)

Robotic systems (DaVinci, Intuitive Surgical)Robotic systems (DaVinci, Intuitive Surgical) OriginsOrigins PrinciplesPrinciples

Stereoscopic visionStereoscopic vision Precision/ surgeon fatigue/ dexterityPrecision/ surgeon fatigue/ dexterity

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

Applicability to other proceduresApplicability to other procedures

*Thomas Payne, Louisiana. Personal communication.

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SO where are we now?SO where are we now?

First TLH 1988First TLH 1988 Now still only 15% of the marketNow still only 15% of the market

First lap prostatectomy in 1990’sFirst lap prostatectomy in 1990’s Biggest series in 2001 around 20 casesBiggest series in 2001 around 20 cases Now 85% are done this wayNow 85% are done this way

First lap chole mid 1980’sFirst lap chole mid 1980’s Now 90% of choles are lapNow 90% of choles are lap Not open unless special reasonsNot open unless special reasons

Despite still higher and plateaued major cx cf Despite still higher and plateaued major cx cf open open

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So what’s the So what’s the problem?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

RecommendationRecommendation

Based on the above discussion and evidence:Based on the above discussion and evidence: When you can do a VH, then do itWhen you can do a VH, then do it

Esp in the context of prolapseEsp in the context of prolapse Other thoughts? See below!Other thoughts? See below!

There is little role for “prophylactic” BSO in There is little role for “prophylactic” BSO in premenopausal subjectspremenopausal subjects Post mp may be differentPost mp may be different

There is little or no role for STHThere is little or no role for STH Esp in context of upper vaginal support with mesh Esp in context of upper vaginal support with mesh

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Recommendation (2)Recommendation (2)

There is NO role for the straight forward TAH There is NO role for the straight forward TAH in 2010in 2010 Unless special circumstances existUnless special circumstances exist

?malignancy. Size not important?malignancy. Size not important In cases of difficulty, bring out the robotIn cases of difficulty, bring out the robot

There is certainly a learning curveThere is certainly a learning curve Easily overcome with time and training, as for lap Easily overcome with time and training, as for lap

cholechole Newer instruments and “crystallizing” of Newer instruments and “crystallizing” of

techniquetechnique Specific item numbers for TLHSpecific item numbers for TLH

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Research directionsResearch directions

Vaginal cuffsVaginal cuffs Rumi-Koh and McCartney/ barbed suturesRumi-Koh and McCartney/ barbed sutures New studies with standardization of techniqueNew studies with standardization of technique

Energy sourcesEnergy sources PK and HarmonicPK and Harmonic Less pain and quicker recovery (MMC study)Less pain and quicker recovery (MMC study)

Repeat randomizationRepeat randomization With all the above, routine With all the above, routine

thromboprophylaxis, antibiotics, Harmonic thromboprophylaxis, antibiotics, Harmonic and mx of the vault and mx of the vault

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Quote from Prof Duncan Turner Quote from Prof Duncan Turner MDMD

Treasurer ISGE, in Editorial, ISGE Newsletter, May 2010 Treasurer ISGE, in Editorial, ISGE Newsletter, May 2010

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

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Thank You!Thank You!

Footnote: the American Association of Footnote: the American Association of Gynae Laparoscopists (AAGL) has now Gynae Laparoscopists (AAGL) has now published a position statement on route of published a position statement on route of hysterectomy. It states that “when hysterectomy. It states that “when hysterectomy is needed, the demonstrated hysterectomy is needed, the demonstrated safety, efficacy and cost effectiveness of safety, efficacy and cost effectiveness of vag hyst and laparoscopic hyst make these vag hyst and laparoscopic hyst make these the procedures of choice” (AAGL Vol18:1, the procedures of choice” (AAGL Vol18:1, 2011).2011).

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