Hysterectomy Trends: A Canadian Perspective on the Past, Present, and Future
2019; Elsevier BV; Volume: 41; Linguagem: Inglês
10.1016/j.jogc.2019.09.002
ISSN2665-9867
AutoresInnie Chen, Abdul Jamil Choudhry, Togas Tulandi,
Tópico(s)Maternal and fetal healthcare
ResumoWith more than 41 000 hysterectomies performed annually in Canada, surgical removal of the uterus is a cornerstone of gynaecologic surgery.1Canadian Institutue for Health Information (CIHI)Inpatient hospitalizations, surgeries, newborns, and childbirth indicators, 2016–2017. CIHI, Ottawa2018https://secure.cihi.ca/estore/productFamily.htm?pf=PFC3714&lang=en&media=0Date accessed: September 17, 2019Google Scholar Soranus of Ephesus is credited with performing the first hysterectomy in the second century ce. He removed a gangrenous prolapsed uterus vaginally; however, the bladder and ureters were also transected.2Ozel B Vaginal hysterectomy: indications, avoiding complications.in: Shoupe D Handbook of gynecology, vols 1-2. Springer International Publishing, Cham, Switzerland2017: 1-15Google Scholar Another notable case is that of Faith Howard, who in 1670 performed an auto-amputation for a completely prolapsed uterus. Although she survived the surgery, she experienced “water passing from her insensible day and night.”3Sutton CJG. The history of hysterectomy.in: Alkatout I Mettler L Hysterectomy: a comprehensive surgical approach. Springer International Publishing, Cham, Switzerland2018: 3-28Google Scholar The first elective vaginal hysterectomy was performed successfully in 1813 by Conrad Lagenbeck of Gottingen, and the first successful abdominal hysterectomy was performed in 1853 by Ellis Burnham of Massachusetts.3Sutton CJG. The history of hysterectomy.in: Alkatout I Mettler L Hysterectomy: a comprehensive surgical approach. Springer International Publishing, Cham, Switzerland2018: 3-28Google Scholar In the 1920s, Johanns Pfannenstiel introduced the transverse incision for abdominal surgery, and in the 1930s, Richardson introduced removal of the cervix as part of total abdominal hysterectomy to avoid cervical discharge and cervical cancer. Aside from these two innovations, in the most recent century, there was little advance in hysterectomy techniques until the advent of laparoscopic hysterectomy, pioneered by Harry Reich.3Sutton CJG. The history of hysterectomy.in: Alkatout I Mettler L Hysterectomy: a comprehensive surgical approach. Springer International Publishing, Cham, Switzerland2018: 3-28Google Scholar By comparison, the current generation of practising gynaecologists have witnessed unprecedented changes in gynaecologic surgical care for women in the past few decades, with the advent of new medications, technologies, and approaches to inpatient care. One of the most striking changes in gynaecology practice is the global decline in hysterectomy rates in recent decades. In the United States, the number of hysterectomies declined consistently each year, from 681 234 procedures in 2002 to 433 621 in 2010.4Wright JD Herzog TJ Tsui J et al.Nationwide trends in the performance of inpatient hysterectomy in the United States.Obstet Gynecol. 2013; 122: 233-241Crossref PubMed Google Scholar Similarly, hysterectomy rates in Canada fell from 484 per 100 000 women in 1997 to 303 per 100 000 women in 2017.5Millar WJ. Hysterectomy, 1981/82 to 1996/97.Health Rep. 2001; 12: 9-22PubMed Google Scholar, 6Canadian Institutue for Health Information (CIHI)Health indicators interactive tool. CIHI, Ottawa2019https://yourhealthsystem.cihi.ca/epub/Date accessed: September 17, 2019Google Scholar Given that 90% of hysterectomies are performed for benign indications,7Canadian Institute for Health Information (CIHI)Health indicators. CIHI, Ottawa2009https://secure.cihi.ca/free_products/Healthindicators2009_en.pdfDate accessed: September 17, 2019Google Scholar the decline in the hysterectomy rate reflects the availability of alternatives, including hysteroscopic surgery, endometrial ablation systems, progesterone-containing intrauterine devices, and hormonal suppressive options.8Rafique S DeCherney AH. Medical management of endometriosis.Clin Obstet Gynecol. 2017; 60: 484-496Google Scholar The introduction of long-term medical treatments (e.g., selective progesterone receptor modulators) for fibroids—a condition that has traditionally been managed surgically—has further obviated the need for surgery for many women.9Vilos G Allaire C Laberge P-Y et al.SOGC clinical practice guideline: the management of uterine leiomyomas.J Obstet Gynaecol Can. 2015; 37: 157-178Abstract Full Text Full Text PDF PubMed Scopus (244) Google Scholar Finally, with advances in assisted reproductive techniques and societal trends of advancing maternal age, women with uterine disorders are increasingly choosing treatment options that preserve future fertility.10Chen I Wise MR Dunn S et al.Social and geographic determinants of hysterectomy in Ontario: a population-based retrospective cross-sectional analysis.J Obstet Gynaecol Can. 2017; 39: 861-869Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar In addition to the declining numbers of hysterectomies performed, the current generation of practising gynaecologists has witnessed a dramatic shift towards minimally invasive endoscopic surgery. Because of its faster recovery period and lower number of complications compared with conventional abdominal approaches, it has become the default mode of hysterectomy for many gynaecologists across Canada.11Chen I Lisonkova S Allaire C et al.Routes of hysterectomy in women with benign uterine disease in the Vancouver Coastal Health and Providence Health Care regions: a retrospective cohort analysis.CMAJ Open. 2014; 2: E273-E280Crossref PubMed Google Scholar, 12Gale J Cameron C Chen I et al.Increasing minimally invasive hysterectomy: a Canadian academic health centre experience.J Obstet Gynaecol Can. 2016; 38: 141-146Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Surgeon uptake of laparoscopic hysterectomy appears to be multifactorial, and self-reports of adequate training and availability of operating room resources appear to be important variables.13Chen I Bajzak KI Guo Y et al.A national survey of endoscopic practice among gynaecologists in Canada.J Obstet Gynaecol Can. 2012; 34: 257-263Abstract Full Text PDF PubMed Scopus (22) Google Scholar A 1983 report by Kilkku et al. suggested an association between reduced sexual function and removal of the cervix and led to an increasing number of subtotal (supracervical) hysterectomies.14Kilkku P Grthroos M Hirvonen T et al.Effects on libido and orgasm.Acta Obstet Gynecol Scand. 1983; 62: 147-152Crossref PubMed Scopus (217) Google Scholar However, this claim was refuted by subsequent studies that showed similar sexual function, quality of life, and rates of pelvic organ prolapse among women undergoing total or subtotal hysterectomy.14Kilkku P Grthroos M Hirvonen T et al.Effects on libido and orgasm.Acta Obstet Gynecol Scand. 1983; 62: 147-152Crossref PubMed Scopus (217) Google Scholar, 15Berlit S Tuschy B Wuhrer A et al.Sexual functioning after total versus subtotal laparoscopic hysterectomy.Arch Gynecol Obstet. 2018; 298: 337-344Crossref PubMed Scopus (19) Google Scholar, 16Andersen LL Alling Møller LM et al.Objective comparison of subtotal vs. total abdominal hysterectomy regarding pelvic organ prolapse and urinary incontinence: a randomized controlled trial with 14-year follow-up.Eur J Obstet Gynecol Reprod Biol. 2015; 193: 40-45Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Furthermore, with removal of the uterine corpus in laparoscopic supracervical hysterectomy by morcellation, there is also a risk of intraperitoneal dissemination of uterine cells, including dissemination of undiagnosed cancer cells, iatrogenic endometriosis, adenomyosis, and parasitic myoma.17Tulandi T Leung A Jan N Nonmalignant sequelae of unconfined morcellation at laparoscopic hysterectomy or myomectomy.J Minim Invasive Gynecol. 2016; 23: 331-337Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar As a result, most practising gynaecologists have abandoned supracervical hysterectomy and perform mainly total hysterectomy. The U.S. Food and Drug Administration approval of the da Vinci robotic surgical system in 2003, and its upgrade in 2014, heralded a new era of laparoscopic surgery, enabling more gynaecologic surgeons to offer minimally invasive hysterectomy to their patients. Compared with conventional laparoscopic hysterectomy, robot-assisted procedures are associated with shorter learning curves, thereby allowing more gynaecologists to perform hysterectomy with a minimally invasive approach. In the United States, hundreds of units have been installed,18Bouquet de Joliniere J Librino A Dubuisson J-B et al.Robotic surgery in gynecology.Front Surg. 2016; 3: 1-8Google Scholar and nearly one-half of laparoscopic hysterectomies are performed with robot assistance, including 39.5% of all benign laparoscopic cases and 72.3% of malignant laparoscopic cases.19Desai VB Guo XM Fan L et al.Inpatient laparoscopic hysterectomy in the United States : trends and factors associated with approach selection.J Minim Invasive Gynecol. 2016; 24 (151–8.e1)Google Scholar Although the overall clinical outcomes appear to be similar for laparoscopic and robot-assisted hysterectomies,20Wright JD Ananth C V Lewin SN et al.Robotically assisted vs laparoscopic hysterectomy among women with benign gynecological disease.J Am Med Assoc. 2013; 309: 689-698Crossref PubMed Scopus (399) Google Scholar the system cost of $2 million per unit and the limited-life reusable instrument cost of $2000 each3Sutton CJG. The history of hysterectomy.in: Alkatout I Mettler L Hysterectomy: a comprehensive surgical approach. Springer International Publishing, Cham, Switzerland2018: 3-28Google Scholar have made system adoption prohibitive in the Canadian health care model. For this reason, with the exception of surgical procedures performed at a few specialized tertiary centres, few hysterectomies in Canada are performed with robot assistance. Despite the introduction of novel technologies to facilitate minimally invasive hysterectomy, Cochrane review and national and international clinical practice guidelines have recommended vaginal hysterectomy as the preferred mode of hysterectomy, given the decreased complications and costs associated with this approach.21Aarts JWM Nieboer TE Johnson N et al.Surgical approach to hysterectomy for benign gynaecological disease.Cochrane Database Syst Rev. 2015; (10–3)Crossref PubMed Scopus (393) Google Scholar, 22Thurston J Murji A Scattolon S et al.No . 377-hysterectomy for benign gynaecologic indications.J Obstet Gynaecol Can. 2019; 41: 543-557Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Although vaginal hysterectomy rates were reported to be on the rise between the 1980s and 1990s, the introduction of laparoscopic techniques has been accompanied by declining numbers of vaginal hysterectomies, with the proportion of hysterectomies performed vaginally falling from 32% to 24.5% in recent decades in Canada.5Millar WJ. Hysterectomy, 1981/82 to 1996/97.Health Rep. 2001; 12: 9-22PubMed Google Scholar, 23Chen I Mallick R Allaire C et al.National technicity on the rise: ten year minimally invasive hysterectomy trends for women with benign uterine disease in Canada.J Minim Invasive Gynecol. 2019; (in press)Google Scholar In 2009, the concept of technicity was introduced to the Canadian gynaecologic community as a measure of the proportion of hysterectomies being performed by minimally invasive techniques. Its use has become a standardized measure of gynaecologic surgery quality in Canada.24Laberge PY Singh SS. Surgical approach to hysterectomy: introducing the concept of technicity.J Obstet Gynaecol Can. 2009; 31: 1050-1053Abstract Full Text PDF PubMed Scopus (29) Google Scholar, 25Chen I Laberge PY. Technicity in Canada: The Long and Short of Hysterectomy Incisions.J Obstet Gynaecol Can. 2019; 41: 1254-1256Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The Canadian Women's Investigators for Surgical Excellence in Research (CanWISER) is a pan-Canadian collaboration of gynaecologic surgeons and researchers, supported by the Canadian Institutes of Health Research and the Society of Obstetricians and Gynaecologists of Canada to study minimally invasive hysterectomy practice in Canada. Using data from the Canadian Institute for Health Information involving 369 740 hysterectomies, this national body of researchers found that the national technicity index increased from 40.5% in 2006-2007 to 63.2% in 2016-2017 for non-cancerous indications.23Chen I Mallick R Allaire C et al.National technicity on the rise: ten year minimally invasive hysterectomy trends for women with benign uterine disease in Canada.J Minim Invasive Gynecol. 2019; (in press)Google Scholar However, both overall hysterectomy rates and minimally invasive hysterectomy rates appear to vary across the provinces. In 2017, Prince Edward Island had the highest hysterectomy rate (469 per 100 000) and Québec had the lowest (259 per 100 000), with other provinces falling in between (i.e., Saskatchewan [416 per 100 000], New Brunswick [389 per 100 000], Nova Scotia [378 per 100,000], Alberta [366 per 100 000], Newfoundland and Labrador [352 per 100 000], Manitoba [342 per 100 000], Ontario [287 per 100 000], and British Columbia [270 per 100 000]).6Canadian Institutue for Health Information (CIHI)Health indicators interactive tool. CIHI, Ottawa2019https://yourhealthsystem.cihi.ca/epub/Date accessed: September 17, 2019Google Scholar Similarly, for minimally invasive rates, technicity for non-cancerous indications was highest in Saskatchewan (83.9%) and lowest in Manitoba (44.4%), with other provinces falling in between (i.e., Nova Scotia [48.5%], New Brunswick [50.3%], Newfoundland [55.2%], Ontario [63.0%], Québec [61.8%], Prince Edward Island [64.3%], Alberta [64.3%], and British Columbia [72.1%]).23Chen I Mallick R Allaire C et al.National technicity on the rise: ten year minimally invasive hysterectomy trends for women with benign uterine disease in Canada.J Minim Invasive Gynecol. 2019; (in press)Google Scholar Although variation occurs among provinces as a result of differences in patient population characteristics, there is a concern that large variations in hysterectomy rates and technicity among geographic regions may also reflect differential access to quality treatment options. Several Canadian studies have suggested that women of low socioeconomic status may have higher hysterectomy rates, with a higher proportion of hysterectomies performed abdominally.10Chen I Wise MR Dunn S et al.Social and geographic determinants of hysterectomy in Ontario: a population-based retrospective cross-sectional analysis.J Obstet Gynaecol Can. 2017; 39: 861-869Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 19Desai VB Guo XM Fan L et al.Inpatient laparoscopic hysterectomy in the United States : trends and factors associated with approach selection.J Minim Invasive Gynecol. 2016; 24 (151–8.e1)Google Scholar The CanWISER research group is in the midst of exploring whether these disparities are occurring at the national level. If so, these findings may have important implications for policymaking and resource allocation to ensure equitable access. The overall decline in hysterectomy and the increasing proportion of minimally invasive hysterectomies has resulted in reduced hospitalization for women with uterine disease. Women undergoing vaginal or laparoscopic hysterectomy typically stay 1 day in hospital compared with 2 or 3 days for women undergoing abdominal hysterectomy. However, many institutions have also implemented same-day discharge after minimally invasive hysterectomy, with comparable outcomes.26Perron-Burdick M Yamamoto M Zaritsky E Same-day discharge after laparoscopic hysterectomy.Obstet Gynecol. 2011; 117: 1136-1141Crossref PubMed Scopus (91) Google Scholar, 27Jennings AJ Spencer RJ Medlin E et al.Predictors of 30-day readmission and impact of same-day discharge in laparoscopic hysterectomy.Am J Obstet Gynecol. 2015; 213 (344.e1–7)Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar For women undergoing abdominal hysterectomy, measures to promote enhanced recovery through multimodal analgesia, including the use of regional abdominal blocks, have led to further decreases in the length of stay.28Bacal V Rana U McIsaac DI et al.Transversus abdominis plane block for post hysterectomy pain: a systematic review and meta-analysis.J Minim Invasive Gynecol. 2019; 26: 40-52Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Together, these interventions promote the normalization of early discharge among both patients and health care providers and help satisfy budgetary constraints in the health care system. Even though hysterectomy techniques have evolved tremendously over the centuries, in recent decades gynaecologists have seen some of the most significant innovations in hysterectomy practice. Women with non-cancerous uterine conditions have more options, including medical alternatives, endometrial ablation, uterine artery embolization, and a variety of minimally invasive procedures. The future will likely see further advances in medical therapies, accompanied by a decreased need for surgical intervention and hospitalization. However, as treatment options become increasingly available, the challenge for the health care system will be to ensure equitable access to these novel and improved therapies across geographic regions and patient populations in Canada. Évolution de l'hystérectomie : un regard canadien sur le passé, le présent et l'avenirJournal of Obstetrics and Gynaecology Canada Vol. 41PreviewCompte tenu des plus de 41 000 hystérectomies pratiquées annuellement au Canada, l'ablation de l'utérus est la pierre angulaire de la chirurgie gynécologique1. Soranos d’Éphèse est réputé avoir réalisé la toute première hystérectomie au deuxième siècle de l’ère chrétienne. Il a procédé à l'ablation d'un utérus prolabé gangréneux par voie vaginale; cependant, la vessie et les uretères ont aussi subi une dissection transversale2. Un autre cas notable est celui de Faith Howard, qui a procédé en 1670 à l'autoamputation d'un utérus complètement prolabé. Full-Text PDF
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