The preferred route of hysterectomy in women without utero-vaginal prolapse in a poorly resourced setting

Abstract

Hysterectomy remains one of the most common operative procedures for benign uterine diseases performed in the world. At the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), the rate of vaginal hysterectomy (VH) was 9.8% before the initiation of this study, mainly performed for utero vaginal prolapse. The main objectives of this investigation was to determine if the use of formal guidelines for selecting the route of hysterectomy, a surgical tree algorithm, and a standardised surgical technique would increase the rate of VH and result in an overall decline in open abdominal hysterectomy (AH). An ancillary to this study would be to define the safety of the VH as compared to laparoscopic assisted vaginal hysterectomy (LAVH), regarding outcome, cost, and complications. Finally, this PhD aims to highlight the favourability and achievability of vaginal hysterectomies, as per international guidelines. Study Design This thesis is comprised of seven articles addressing the main objectives of the study. All women admitted to the Department of Obstetrics and Gynaecology at CMJAH between July 2001 and December 2014 for hysterectomy, meeting the guidelines criteria were included. The residents in training, under the supervision of the primary investigator (PI) or specialists with large experience in vaginal surgery performed the VH procedures. The secondary objectives included a retrospective study addressing the outcome and cost difference between VH and LAVH over a period of two years (2015-2016) and a prospective randomised control study from January 2017 to December 2019 comparing VH and LAVH. In addition to the patient characteristics and surgical approach to hysterectomy, length of hospital stay, intra operative and immediate post-operative complications, and cost were recorded and analysed. Results The implementation of the teaching programme has seen an increase in the rate of VH from 9.8% to 19.2% by 2008. By the end of this study, the rate increased to 48.4%. This resulted in an overall decline in open AH from 91.2% to 51.6%. The VH/AH ratio increased from 1/9 at the beginning of the study (July 2001) to 1/1 by its end (December 2014).During the study period, 1143 vaginal procedures (1017 VHs and 126 LAVHs) were performed. The results maintained thereafter with the VH/AH ratio of1/1 (49.7% VH and 50.3%TAH) by the end of vi December 2019. Regarding cost analysis, LAVH was found to be more costly mainly due to prolonged operating times and the consumables used. The prospective randomised control study confirmed that both procedures, VH and LAVH, are safe, share the same benefits, and demonstrate no major difference in complication rates and blood loss. In all cases, VH was successfully performed and was less costly. LAVH found to be more expensive mainly to longer operating time and the use of consumables. Conclusion The use of institutional guidelines for determining the hysterectomy route, a surgical tree algorithm, and a standardised VH technique resulted in an increased number of VHs performed. This provided an essential opportunity for residents to acquire, improve, and maintain the skills required to perform VH safely. This information has been deliberately disseminated through international guidelines by the author, as the lead author with other collaborators following an exhaustive peer review process