Which Hysterectomy in 2010?

1. Which Hysterectomy in 2010? A user’s guide to everything CHOICE magazine doesn’t tell you. Philip Thomas FRANZCOG FRCS

2. 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

3. Medicare data- route of hysterectomy(*no specific item number for TLH) (Molloy, D, O&G 2010, 12:1, 30-31)

4. USA data600,000/yr. By age 65, 33% will have had a hysterectomy (Journal ACOG, Oct 2009)

5. 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

6. 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

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

8. 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?

9. Indications for hysterectomy • Various others • Adenomyosis • PID • Chronic pain • PPH • Cornual ectopics • Sterilisation Farquar and Steiner Obstet Gynaecol 2002;99:229

10. 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

11. Sub total hysterectomy3 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.

12. 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?

13. Contraindications • Hyster for cx dysplasia • PCB/IMB/heavy discharge • Known endo hyperplasia or cancer • Patient unwilling/unable to continue Pap smears

14. Role of prophylactic oophorectomyPre-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.

15. Role of prophylactic oophorectomyPre-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.

16. 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

17. Classification of the “Lap hyster” Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterectomy a a waste of time? Lancet 1995;345-6

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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.

25. 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

26. 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

27. 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.

28. 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

29. So what’s the problem? 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

30. 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

31. 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

32. 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

33. Quote from Prof Duncan Turner MDTreasurer 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”

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