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FROM VAGINAL HYSTERECTOMY TO LAPAROSCOPIC HYSTERECTOMY: IS THERE A NEED?

Prof.  A. Chrysostomou   MD, FCOG (SA), Mmed (Wits) Senior Specialist, Department of  Obstetrics and Gynecology, Johannesburg Hospital  University of Witwatersrand

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Hysterectomy: Is one of the most common operative procedures for benign gynaecological conditions performed today Can be performed abdominally, vaginally, laparoscopically, robotic assistance  MIH (VH and LH/RH) are preferred to open AH, mainly avoiding large painful abdominal incisions and prolong hospitalization Since the introduction of LH/RH,  VH  underutilised, efforts to be replaced Controversy continues Is There a NEED  to  underestimate  the benefits of VH by insisting  on  LH?

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Vaginal Hysterectomy dates back to ancient times  and was performed by : -  Themison  of Athens in 50 BC -  Soranus  of Greece in 120 AD - In  Alsaharavious ’ writings of 11 th  century “if uterus prolapsed  extremely and could not be reinserted, it should be surgically excised” - In 17 th  century first successful, self  vaginal hysterectomy by Faith Howard - First planned vaginal hysterectomy 1813 by Conrad  Langenbeck -  Heany  in 1934 reported a series of 627 VH for benign disease

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Abdominal Hysterectomy  was introduced  by the General surgeons in  first part of the 20 th  century Not being familiar with the vaginal surgery favoured the abdominal route In 1843, Charles Clay the first recorded subtotal abdominal hysterectomy In 1929, Richardson in the USA performed the first total abdominal hysterectomy

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Despite Richardson’s  recommendations, subtotal hysterectomy     remained the preferred technique until the late 1940s. The advent of antibiotics, blood transfusion, modern anaesthesia, the     recognition that cancer occasionally developed in the cervical stump     lead to an increase of total abdominal hysterectomies  Improvement in surgical technique, the introduction of   Pfannenstiel     incision with cosmetic results, safety lead to explosive increase of the     total abdominal  hysterectomies seen today

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LAPAROSCOPIC  HYSTERECTOMY:  Kurt  Semm  in Germany first described the LAVH, in 1984, In 1989, Harry Reich introduced the first total laparoscopic hysterectomy.  Nowadays, there are a number of different subtypes of laparoscopic hysterectomy defined by the extend of laparoscopic contribution towards the vaginal hysterectomy Despite many being against LAVH, this procedure appears to be a real alternative for hysterectomy by laparotomy but not a routine. It is  new technique for an old procedure: VH

Table 2 Richardson staging of laparoscopic hysterectomy (22 trials)
Stage Laparoscopic content
o
1
2
3
4
5
Laparoscopy performed but no
laparoscopic procedure before vaginal
hysterectomy
Procedure includes laparoscopic
adhesiolysis or excision of endometriosis
Either or both adnexae freed
laparoscopically
Bladder dissected from uterus
laparoscopically
Uterine artery transected laparoscopically
Anterior or posterior colpotomy or entire
uterus freed laparoscopically
Included trials
Ottosen20
No trial
Kunz,13 Marana,17 Raju22
Ferrari,g Long,15 Tsai30
Darai,6 Ellstrøm,7 Olsson,19 Schutz,25
Soriano,27 Summitt,28 Summitt,29 Yuen31
Falcone,8 Härkki-Sirén,11 Hwang,12
Langebrekke,14 Long,15 Perino,21 Ribiero,24
Seracchioli26

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The  rationale for LAVH is to convert an abdominal hysterectomy into laparoscopic/vaginal procedure or a difficult VH into easy one, and not to replace VH   Kovac  and colleagues demonstrated that by performing Laparoscopy before TAH on women for whom VH was judged unsuitable, laparoscopic findings reveal that 91,3% women could and did undergo an uncomplicated VH   Obstet   Gynecol  2000; 95: 787-93

RESEARCH ARTICLE
Implications of performing laparoscopic-
assisted vaginal hysterectomy versus
abdominal hysterectomy on suitable
patients in a South African hospital
setting
Andreas Chrysostomou, MD. FCOG, MMed
Departn-lent: Of Obstetrics and Gynaecology, Johannesburg Hospital and University Of the
Witvvatersrand. Johannesburg

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All large-scale surveys of hysterectomy practice show that 70-80% are performed via abdominal approach, except for utero-vaginal prolapse, where the vaginal route is used Vaginal hysterectomy accounts 10% of all hysterectomies performed

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The preferred route of hysterectomy: Continuing Conundrum  Comparison among different approaches to Hysterectomy The search includes Medline/ PubMed and Cochrane data based review  English language articles were reviewed from 2004 onwards.  Key clinical questions that  led  to search were :

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Comparison of the different routes of hysterectomy

Short term outcomes :  - Operation time                                          - Complications                                          - Hospital stay                                          - Blood loss                                          - Re-look or second look lap/ lapscope Cost Ethical considerations    Should be taken into account when justified the need to move from VH to LH

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What   is the Evidence for the Route of Hysterectomy?

Nieboer  TE “Surgical approach to hysterectomy for benign gynaecological disease” The three approaches to hysterectomy were analysed ( Cochrane Database System Review ) There were 34 randomized controlled studies with 4495  women VH and LH same benefits as compare to  AH Less complication with VH as compare to LH, shorter operation time by 39,3 minutes, less costly and no significant differences in hospital stay

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Aarts  JWM “ surgical approach to hysterectomy for benign gynaecological disease” (Cochrane Database Syst. Rev.  2015)   The five approaches to hysterectomy  were analysed (AH, VH, LH, TLH, R-LH) Included only RCTs. 47 studies with 5102 women  Authors conclusion:- VH appears to be superior to AH and LH as it is associated with shorter                                        operation time, faster return to daily activities and fewer febrile episodes                                        postoperatively                                            -   No advantages of LH over VH could be found                                            - LH had longer operation time, and TLH had more urinary tract injuries                                            - No benefits of RH over LH, (two RCTs ,152 women) Same conclusion: LH is associated with increase risk of urinary tract injuries.  When VH is not feasible LH may avoid the need for AH.

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Human Vol.26, No.7 pp. 1741—1751, 2011
Advanced Access publication on May 3. 201 1 d&lO.1093/humrep/derl 16
human
ORIGINAL ARTICLE
Gynaecology
reproduction
FINHYST, a prospective study of 5279
hysterectomies: complications
and their risk factors
Tea H.I. Brummer Jyrki Jalkanen l, Jaana Fraser2,
Anna-Mari Heikkinen 3, Minna Kauk04, Juha Mäkinen 5, Tomi Seppälä6,
Jari Sjöberg l, Eija Tomas 7, and Päivi Härkki I
of Obst«rics nd Gna«olgy. Hdshkj Uriversity Cmtral 140. Y-US. friand 2Dqartrrmt of
Obstetrics and Gynecd0ü. North Krelia Central Hospital. Tikkarnåmtie 16 0210 Jærsuu. Fhlard bepa--trnem of Obstetrics ard
Gyna«olcgy, Ku'pio Uni'.ersity Hospital. Box 1777, 7021 1 Ku.io, Finland cf Gynae:olqy, Su'men Terveystdo,
I I , W520 Helsinki, Finland SDepartm&'t of Obstetrics nd Gyrzecoloy, Turfu I-Jriæßity Hospital, PO Box 52, X)S21 Turku,
Finland 'unit of Quantitzive Methods in &oromics and Manaæment *Érce. Aalto Uri'.ersity. 1210. Hdshki. Firland
7Tu-npe•e PO Box 33521 Tamßre.

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COMPLICATIONS OF HYSTERECTOMY, WITH COMPARISON APPROACHES  Human  Reprod  2011

COMPLICATION AH LH VH Operative  hemorrhage >1000ml 5.7% 3% 1.6% Bladder injury 0.9% 1% 0.6% Ureter injury 0.3% 0.3% 0.04% Bowel injury 0.2% 0.4% 0.1% Infection total (UTI,  wound infection, febrile events, pelvic infection) 7.7% 6.7% 5.2% Major  complications total ( thrombosis,organ  injury, reoperation) 4% 4.3% 2.6% Complications Total 19.2% 15.4% 11.7%

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Morelli  et al  2007. A prospective randomised control study comparing TLH to VH 				 ACOG-position statement(2009): route of hysterectomy to treat benign uterine disease, VH should be approach of choice. LH is an alternative to AH for those patients in whom a VH is not indicated or feasible. AAGL- position statement (2010): Adopted this statement and moved a step forward. Advising that surgeons without requisite experience and skill are required to enlist the aid of colleagues to or refer the patients to such colleague.

TLH VH Haemorrhage 7%  2.5% Ureteric injury  2,5%  0% Operating time  86 min  46 min

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VH as compare to LH:- shorter operation time by 39,3 minutes ( Nieboer  et.al)                                            - 46 minutes ( Morelli  et.al)                                            - Johnson in 2005 Cochrane review, 27 RCTs, 41,5 minutes                                            - Richardson et.al (1995) found that TLH can take as much as three                                                    times  longer compared to VH. They suggested that if LH is done, it should                                                    be  converted to vaginal procedure as early as possible to reduce the overall                                                    operating  time . They concluded that “LH does seem to be a waste of time for most patients” The famous Doyen: insisted in 1939 “ no one could call himself a gynaecologist until  he performed  a VH in private”

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Safety, cost effectiveness, and superiority of VH was demonstrated, LH cost an average £400 or €570 more than VH (  Sculpher , BMJ 2004) Cost effectiveness analysis : A potential of saving of US$ 1,2 million for every     1000 hysterectomies performed vaginally and also 20% reduction in   complication rates.( Kovac  et.al IJOG 2000)  RH= $2189 more per case compared to TLH.  Economic viability? The main sources of the cost differences are related to operation time and consumables used during LH as opposed to V H

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Cost analysis of vaginal hysterectomy as compared to laparoscopic assisted vaginal hysterectomy for non-prolapse uterus in a tertiary institution in South Africa         Andreas  Chrysostomou a  Innocent  Maposa b,c   A prospective randomized controlled trial comparing vaginal and laparoscopic assisted vaginal hysterectomy in absence of uterine prolapse in a tertiary institution in South Africa     Andreas Chrysostomou1,Dusan Djokovic2, Elena Libhaber3,William Edridge4, Bruno J. van Herendael5 Potential of saving 1.2-1.4 Million USD for every 1.000 hysterectomies performed vaginally as opposed to LH

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From VH to LH: is there a need? Results of the literature review

The ratio AH:VH remains very high in spite the introduction of LH/RH Comparing the three routes of hysterectomy (TAH,VH,LH/RH): VH and LH appears to be superior to AH - associated with shorter hospitalization, less need of analgesia, faster mobilization and return to daily activities, cosmetic VH found to be faster, scar less, fewer complications and less costly, as compared to both: LH and AH Can be performed by using regional (spinal) anaesthesia   LH is associated with more visceral  ureteric complications , major haemorrhage and return to theatre as  compared  to VH and TAH

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Since the introduction of LH, the concept of MIH emerged….   The question is why VH, a long-practice procedure dating back to  Themison  50 BC, following all the parameters of MIS non scar hysterectomy does not hold preferential place amongst surgeons with LH/ /RH/AH routes being the first choice?   Reimbursement for hysterectomy by Medical aids is more for AH/LH and RH, than VH for patients with similar indications and uterine weight? Discrepancy between preferences and practices amongst  gynaecologists demonstrated  in all surveys  Preferred and actual methods of hysterectomy: A survey of current practices among members of the South African Society of Obstetricians and Gynaecologists A Chrysostomou,1 MD, FCOG (SA),  MMed ; D Djokovic,2,3 MD,  PhD SAJOG, Vol  26, No 1 (2020)

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The effect of LH on the total number of VH

There is a common perception that VH has been sacrificed at the expense of LH and is felt to be attributed to the industry A  large scale  surveys  in USA 1998-2010: VH decline from 24,8% to 16,7% In Norway the increase in LH  led  to the decrease of VH below 10% In Australia between 2001-2015, 53% decrease in the rate of VH In Denmark (1997-2011) : An increase In LH, decrease in AH, VH stay the same LH increases at the  expense  of  a reduction in VH  The superiority of hysterectomy by the vaginal route is not denied

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The Impact of RH on the Rates of AH, LH & VH

Jason D Wright 2013  JAMA  “Robotically Assisted vs Laparoscopic Hysterectomy Among women with Benign Gynaecology Disease”: Cohort study of 264758 women underwent hysterectomy for benign gynaecological disorders at 441 hospitals across the USA The number of  robotically assisted hysterectomy increased from 0,5% in 2007 to 9.5% in 2010 During the same period, AH decrease (44% to 35%) ,LH decrease (15,5 %  to 8,6%)   and VH  decrease (24,8% to 16,7%)  In hospitals where RAH was not introduced : 46.6%. Underwent TAH, the rates of VH decrease ( from 22% to 20% ), LH increase  (24% to 34%)

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Nigeria: -Vaginal hysterectomies: 12% due to utero-vaginal prolapse, as reported in 2013.                    - Registrars in training observe up to 5 VH during residence time South Africa : Luck of nationwide statistics. Five VH before sitting the fellowship                            examination                            CMJAH: < 10% mainly due to utero-vaginal prolapse (2001 institutional rates)      Restrictive use of vaginal hysterectomy:  Another skill disappearing?  How to increase VH?

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Factors implicated in declining of VH   (ACOG- 2011)

Less emphasis on vaginal surgery in residency training programs Absence of clear guidelines for selecting appropriate candidates  for VH  Physician practice style and habits Lack of patient knowledge about surgical options

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Vaginal  hysterectomy has fallen out of favour more than once.  At the turn of the 21 st  century, a new threat is appearing with the development of TLH and RH Existing recommendations have been ignored and never  been subjected to any critical reviews Current evidence suggests that a physician’s training and expertise are the only considerations in selecting the route of hysterectomy  The benefits and hazards seems to be dependent on surgical expertise which influences the decision

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An  interesting observation globally: Most situations where LH has been introduced, the number of LH performed steadily increases, without a significant reduction in AH, but a decline in  VH In USA, the number of hysterectomies performed vaginally is decreasing . Antosh   et al.  (2011)  in a survey amongst residents: “A resident opinion on VH training” found that 41,7%  reported VH as their preferred route, compared to 47%  who preferred TLH  Expert advice for today’s OBGYN (2013) by R. Ted Lee “ vaginal versus laparoscopic hysterectomy” stated : “TLH should be the new gold standard in minimally invasive approaches. Professional societies such as ACOG, AAGL should direct more resources to promote education in and practice of LH if a substantial decrease in AH is truly our primary goal.”

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Considering the short and long term results, an improvement in patients’ quality of life, cost effectiveness and cosmetics are to be achieved; VH fulfills all these  requirements When combined with laparoscopic assistance it may represent the best option amongst all possible routes Each academic institution should asses its own AH:VH ratios. There is a need for vaginal/ laparoscopic hysterectomy training programs in every country and academic  institution In our institution, the initiation of “Vaginal/Laparoscopic assisted vaginal hysterectomy training program” in 2001 lead to a dramatic increase in VH and a decline in abdominal and laparoscopic hysterectomy

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Figure 1 : Guidelines for detamining Ole route of hysterectomy for
benign disease (Approch clinical
Or weight <2EO-360y?
Or uterine Jet-8th <12cm width
evaluation
for laparoscopic correction or
Vagina
TAH

How to increase VH Challenging existing CI in favour of VH or LAVH  The use of Guidelines for determining the route  of  hysterectomy: Uterine accessibility, uterine size, pathology confined to the uterus  are proposed for VH. Surgical tree algorithm Standardized surgical technique Evidence-based  guidelines for vaginal hysterectomy of the International Society  for Gynecologic   Endoscopy (ISGE ) Andreas  Chrysostomou ,  Dusan   Djokovic,  William  Edridge , Bruno  J van  Herendael .  Eur   J  Obstet   Gynecol   Reprod  Biol.  2018;231:262-267.  Evidence-based  practical guidelines of the International Society for  Gynecologic   Endoscopy (ISGE ) for vaginal  hysterectomy. Andreas  Chrysostomou ,  Dusan   Djokovic,  William  Edridge , Bruno  J van  Herendael .  Eur   J  Obstet   Gynecol   Reprod   Biol. 2020;252:118-126 .

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20
18
16
- 12.2
12
1 0-2
9-8
10
8-2
8
1 9.4
1 9-2
17.6
1995
1 996
1 997
1 998
1 999 2000
152
2001 2002 2003 2004

Vaginal hysterectomies performed at the Johannesburg General Hospital as a percentage of all hysterectomies from 1995 to 2004

Hysterectomy Guidelines  were introduced in 2001. The percentage of vaginal hysterectomies performed  increased by more than 5% that year, and remained substantially higher than preceding years.

Implications of performing laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy on suitable patients in a South African hospital  setting. A  Chrysostomou , SAJOG 2008;14(2):

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VH and LAVH Performed at  CMJAH  as a Percentage of all  Hysterectomies from 1995 to 2015

LAVH 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 6 7.2 9.5 10 11 5 3 3 3 2 3 2 5.2 2 4.0999999999999996 VH 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 7.9 11.6 12.2 10.200000000000001 8.2000000000000011 9.8000000000000007 15.2 17.600000000000001 19.399999999999999 19.2 19.8 21 22 23 28 32 39.800000000000004 38.200000000000003 38.9 48.4 42.4

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Formal  institutional guidelines promotes the vaginal approach to hysterectomy in patients with benign disease and non-prolapsed  uterus.   Andreas  Chrysostomou ,  Dusan  Djokovic, Elena  Libhaber , William  Edridge , Bruno J van  Herendael EJOGRB. 2021;259:133-139 .

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VH 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 8.2000000000000011 9.8000000000000007 15 17.600000000000001 19.399999999999999 20 20 21 22 23 28 32 39.800000000000004 38.200000000000003 38.9 48.4 42.6 45.5 45 49.5 48.2 LAVH 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2 7.2 9.5 10 5 5 3 3 3 2 3 2 5.2 1.2 4.0999999999999996 9.5 10.200000000000001 9.6 11.8 TAH 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 91.8 90.2 85 82.4 80.599999999999994 80 80 79 78 77 72 68 60.2 61.8 61.1 51.6 57 52.5 54.8 51.5 51.7

A randomized controlled trial comparing  vaginal and laparoscopically-assisted vaginal hysterectomy in the absence of uterine prolapse in a South African tertiary institution  Andreas  Chrysostomou ,  Dusan   Djokovic,  Elena  Libhaber ,  William  Edridge ,  Mary  Kawonga   and Bruno J. van  Herendael . Submitted for publication

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This presentation highlights  the fundamental problem being faced in clinical gynaecology  If  there is a lack in adequate training being offered in VH, it will result in a new generation of gynaecologist performing TLH in patients who may have otherwise undergone an uncomplicated  VH and If  the appropriate steps are not taken, the art of  performing VH will die; and this is a tragedy, considering the benefits offered by this approach

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As minimally invasive gynaecologic surgeons, our responsibility is to provide the best possible care, proven by careful review of the evidence The future surgical relationships with our patients will depend on whether we make our surgical decisions based on evidence, or because of our lack of surgical expertise, or as a response to newly developed skills Laparoscopy has a place. The specifics should be debated The same is true of robotics The choice is ours to make Let us not sacrifice vaginal hysterectomy on the altar of this debate

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As minimally invasive gynaecologic surgeons, our responsibility is to provide the best possible care, proven by careful review of the evidence The data regarding the method of hysterectomy are now clear The future surgical relationships with our patients will depend on whether we make our surgical decisions based on evidence, or because of our lack of surgical expertise, or as a response to newly developed skills Laparoscopy has a place. The specifics should be debated The same is true of robotics The choice is ours to make Let us not sacrifice vaginal hysterectomy on the altar of this debate

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Factors implicated in decline of VH   (ACOG- 2011)

Less emphasis on vaginal surgery in residency training programs Absence of clear guidelines for selecting appropriate candidates  for VH  Physician practice style and habits Lack of patient knowledge about surgical options (not aware)  Compounding factors may also impair decision making

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20
18
16
12
10
1 9.4
17.6
1 9.2
-12.2
11 .6
1995 1996 1997
10.2
15.2
9.8
8.2
1998 1999 2000 2001
2002 2003 2004 2005

Figure 1
Vaginal Hysterectomies performed at Johannesburg General Hospital as a
percentage of all hysterectomies from 1995 & 2004

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VH and LAVH Performed at CMJAH as Percentage of all  Hysterectomies from 1995 to 2015

VH 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 7.9 11.6 12.2 10.200000000000001 8.2000000000000011 9.8000000000000007 15.2 17.600000000000001 19.399999999999999 19.2 19.8 21 22 23 28 32 39.800000000000004 38.200000000000003 38.9 48.4 42.4 LAVH 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 6 7.2 9.5 10 11 5 3 3 3 2 3 2 5.2 2 4.0999999999999996

Gynae Statistics October 2015

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