Hysterectomy risks quantified in major international study

New, less invasive forms of hysterectomy carry a risk of complications that should be discussed with patients before surgery, according to the author of a landmark study that analysed 32,000 operations in three countries.

New research published in the International Journal of Gynaecology and Obstetrics found that one in 67 (1.5%) vaginal and laparoscopic (‘keyhole’) hysterectomies had to be ‘converted’ to open surgery during operations, increasing the risk of ill health afterwards.

Meghana Pandit, a consultant gynaecologist, Chief Medical Officer and Deputy Chief Executive of University Hospitals Coventry and Warwickshire NHS Trust, said women undergoing surgery needed to be aware of the risks associated with the different methods of performing a hysterectomy, which could leave them needing further operations or with longer-term health problems.

The research – the largest ever international study of its kind – looked at hospital data from England, the USA and Australia collected by the healthcare data informatics company Dr Foster as part of its Global Comparators programme, which brings together clinicians from leading hospitals in 12 countries.

Around 60,000 women undergo a hysterectomy each year in the UK. By the age of 60, one in five women in the UK and one in three in the USA are likely to have had a hysterectomy.

All forms of hysterectomy are generally very safe, and death from surgery is extremely rare. But until now, no major international study has set benchmarks for the risk of ill-heath following an operation (referred to as ‘morbidity’) of the three main types of procedure – abdominal (‘open’), vaginal and laparoscopic hysterectomy.

While a majority of hysterectomies (53%) continue to be performed abdominally by open surgery, the trend in recent years has been for more vaginal and laparoscopic procedures, which are less invasive and typically have a much shorter length of stay in hospital and faster recovery times. Younger women aged 30-60 are more likely to undergo these types of hysterectomy.

Analysing over 32,000 cases of hysterectomy for benign diseases, the researchers examined the risk of “conversion” – the need to switch to open surgery midway through an operation in the event of complications during vaginal or laparoscopic hysterectomy, such as major internal bleeding.

They found that traditional abdominal hysterectomies carry the highest risk of bleeding and readmission to hospital within seven days, as well as having the longest average stay in hospital.

But the study also identified that vaginal and laparoscopic hysterectomies had a 1.5% incidence of conversion to open surgery during the operation (483 of the 32,181 cases studied), equivalent to 1 in every 67 operations.

Conversion cases, moreover, carried by far the highest risk of bleeding (haemorrhage) (7.5% vs 2.4% for abdominal, 1.8% vaginal, and 1.2% laparoscopic) and readmission to hospital within 28 days (5% vs 4.2% for abdominal, 3.1% vaginal, and 2.8% laparoscopic).

In turn, this can leave women needing further surgery or a blood transfusion, or with longer-term health problems, including wound infections and damage to surrounding organs such as the bowel or bladder. It can also leave them more prone to deep vein thrombosis or pulmonary embolism (a clot in the vein or lung).

And the cost to the NHS of performing hysterectomy with complications can be as high as £12,278, which does not include costs from extra time in hospital.

Prof Pandit said:

“Most women choosing a hysterectomy do so because they want to improve their quality of life. They may have suffered years of heavy periods, pelvic pain or prolapse and many are still relatively young and fit. So it’s very important that when a clinician is discussing hysterectomy options with their patient they tell them about morbidity risks associated with the different methods of hysterectomy. Patients should be clearly advised that conversion during surgery is associated with higher rates of problems afterwards.

“We need to keep a close eye on conversion rates to ensure that it is a rare complication of surgery when needed, and not a common occurrence. If these conversions become frequent, it may indicate that the preoperative assessment was inadequate, case selection was incorrect or that there’s a training issue.

“We suggest that all gynaecologists performing hysterectomy record their surgical morbidity outcomes using this study as a benchmark and use it to counsel women undergoing hysterectomy.”

Prof Pandit added that, as a result of the research, her hospital has now set up “morbidity scorecards” for every single surgical speciality, allowing groups of surgeons to look at their figures on a monthly basis and learn from them where necessary to improve patient care.

David Rose, Chief Executive of Dr Foster, said:

“This is an incredibly important piece of international research made possible through detailed analysis of data from leading hospitals around the world.

“It sets new benchmarks around what patients can expect from different forms of hysterectomy and will be invaluable for patients and clinicians in deciding the right care for them.

“The whole idea of our Global Comparators programme is to bring together the world’s leading hospitals to share knowledge and data with a view to improving care for patients.

“As such, this study highlights the value of looking not just at our own, national datasets, but forging partnerships with other health systems that give us deeper insight into clinical challenges affecting all countries and relevant to all patients.”

Bruce Ramsay from the Royal College of Obstetricians and Gynaecologists (RCOG), said:

“It is good to see this international data being presented in a way that gives additional information to women and their gynaecologists when discussing hysterectomy.

“Once the decision for hysterectomy has been made all women should then have a full discussion about their options before giving informed consent.

“Whilst not all gynaecologists perform all three routes of hysterectomy, it is important that they should discuss all options with the patient.  The patient then has the right to be referred on to another gynaecologist if necessary. Different patients may have quite different risks of complications based on their underlying pathology, previous surgery and co-morbidities, so discussions should be individualised for every patient.”

Research published in the following articles:
The BMJ – Risk from less invasive hysterectomy are quantified in study
The Daily Express – Hysterectomy: ‘Non invasive’ procedure to remove womb could increase risk to patient

 

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