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Hysterectomy in a decade of change: more than a weighty matter
OTHER GYNECOLOGIC SURGERY
Surgical Complications Risk Factor Age $65 years Medicaid/ no insurance (compared to private/ Medicare/HMO Academic medical center (compared to non-teaching hospital)
Medical Complications
Adjusted odds ratio
95% CI
Adjusted odds ratio
95% CI
1.73 1.36
1.58, 1.90 1.26, 1.47
4.54 1.62
4.16, 4.96 1.48, 1.77
1.86
1.74, 1.99
3.28
3.06, 3.52
Conclusions: Surgical complications of hysterectomy are more common, occur in younger women, and are associated with higher hospital charges than medical complications. Complication rates vary widely between hospitals, with teaching hospitals having the highest rates. This difference persists after adjustment for coded comorbidities. Possible explanations for the inability of multivariate analysis to explain the wide range in observed complication rates include 1) shortcomings in the available data or models, such as variability in coding practices between hospitals or variability in surgical difficulty between hospitals that is not captured with ICD-9-CM codes (eg, uterine size, cancer stage) and 2) variability in the quality of care between hospitals. Further research is needed to help determine the role of each of these explanations. Risk adjustment methods that use administrative data based on currently available coding standards are poor predictors of surgical complication rates after hysterectomy and should not be used to reach conclusions about quality of care.
Functional outcomes and satisfaction after abdominal hysterectomy Anne M. Weber, MD, Mark D. Walters, MD, Leslie R. Schover, PhD, James M. Church, MD, Marion R. Piedmonte, MA Cleveland Clinic Foundation, Cleveland, Ohio Objective: To compare urinary, lower gastrointestinal (GI), and sexual function and to describe patients’ expectations and satisfaction before and after hysterectomy. Methods: Forty-three women completed questionnaires before and about 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, lower GI, and sexual function were assessed. Women responded with “agree,” “disagree,” or “neutral” to statements about treatment options, the decision for hysterectomy, expectations about surgery and recovery, and satisfaction with their relationship with their doctor and their treatment. Comparisons were made between preoperative and postoperative responses. Statistical significance was accepted for P 5 .002 to account for multiple comparisons. Volume 5, Number 4, 1998
Results: The mean age was 45.4 6 6.7 years. Sixty percent were white, and 88% were premenopausal. The most common indication for hysterectomy was myomas in 76%. There were no statistically significant changes in urinary or bowel symptoms before and after hysterectomy with preoperative symptoms resolving in some women after surgery, and developing in others. Fewer women experienced abdominal bloating after hysterectomy than before. Frequency of intercourse and satisfaction with their sexual relationship did not change in the 34 sexually active women. The level of satisfaction with their treatment and their relationship with their doctor was very high. Conclusion: Women experience a high degree of satisfaction with treatment 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, GI, or sexual function occur frequently before and after surgery, but hysterectomy does not result in consistent changes.
Hysterectomy in a decade of change: more than a weighty matter John H. Kirk, MD, Beth Y. Karlan, MD, Patricia Cane, PhD, Kimberly Gregory, MD, MPH Department of Obstetrics & Gynecology, Cedars Sinai Medical Center & UCLA School of Medicine Objective: Hysterectomy is the second most common surgical procedure performed in the United States. Interest to decrease use of hysterectomy has focused on developing explicit criteria for surgery, peer review and second opinion, as well as changing reimbursement incentives. The purpose of this study is to describe the change in the number of hysterectomies, the indications for hysterectomies, and the histopathology of hysterectomy specimens over the last 10 years at one private, nonprofit, academic, community hospital that does not have a formal system for monitoring hysterectomy use. Methods: Retrospective study utilizing administrative data matched with pathology reports for nonmalignant hysterectomies performed in 1985, 1990, and 1995. Uterine weight and histopathologic diagnoses were recorded. When pathology reports were unavailable, cases were reviewed to determine if the indication was related to prolapse or urinary incontinence. Outcome measures included number of procedures performed, indications for procedures and uterine pathology (uterine weight, histopathology). We utilized the Cochran-Mantel-Haenszel x2 and the Kruskal-Wallis rank sum statistic (P , .05). Results: The number of hysterectomies declined from 631 in 1985 to 461 in 1995 (P 5 .007). The median uterine weight increased (P 5 .0007), and there was a decrease in the number
203
OTHER GYNECOLOGIC SURGERY of specimens with absent histopathology, decreasing from 6% in 1985 to 3% in 1995 (P 5 .013). This difference was explained by changes in the number of procedures performed on patients with private insurance and HMO reimbursement (P 5 .018). Conclusions: While the proportion of surgeries performed for specific indications did not change, the number of hysterectomies performed decreased, and there were fewer normal specimens.
Prediction of endometrial ablation success by preoperative findings William F. Ziegler, DO, Cynthia Sites, MD, Gary Badger, MS, Mousa Shamonki, BS Dept of OB/GYN and Biostatistics, University of Vermont College of Medicine, Burlington, Vermont Objective: To determine the influence of preoperative findings on the outcome of hysteroscopic endometrial ablation. Design: We performed a retrospective chart review of 80 women between the ages of 25 and 50 years who underwent an endometrial ablation for menorrhagia or menometrorrhagia from 1992 to 1996, through a university reproductive endocrinology clinic. Materials and Methods: All eligible patients had a detailed subjective history obtained for duration of dysmenorrhea (Dys) and menorrhagia or menometrorrhagia (Men). Each had a preoperative transvaginal pelvic ultrasound with documentation of the uterine cavity contour and if an intramural myoma was present. A gynecological examination was ascertained from the patients clinical record with regard to uterine size. A benign Papanicolaou smear within 1 year of surgery and a normal endometrial biopsy was required for inclusion. Those with evidence of carcinoma or menopausal symptoms were excluded. Each patient had endometrial preparation with either danazol, GnRHa, or progestin. All ablations were performed by the same surgeon with “rollerball” electrocautery. Those patients who required medical management or additional surgery to control their vaginal bleeding during follow-up were designated as ablation failures. The use of stepwise logistic regression with ablation outcome as the dependent measure was used along with univariate analyses via x2 and t test to compare successes and failures on specific characteristics. Results: The sample was divided into two groups, success (group 1) or failure (group 2), and were matched for gravity, parity, and uterine size. Between the two groups there were no significant differences in the duration of menorrhagia/ menometrorrhagia or dysmenorrhea. Additional therapy was required in 41% of the study group, designated as failures. The length of follow-up was 36 months for group 1 and 27.7 months for group 2. The results are summarized in the table below. 204
Group N Mean age (SD) Normal uterine cavity Intramural fibroid
1
2
P Value
47 (59%) 40 (65.23) 60% (28/47) 18% (8/44)
33 (41%) 41 (64.38) 39% (13/33) 34% (11/32)
.06 .07 .10
The difference in age between the two groups strongly suggests a tendency toward failure with increasing age (P 5 .06). The diagnosis of a normal uterine cavity preoperatively shows a trend for a successful outcome (P 5 .07) when compared with the presence of an intracavity lesion, fibroid, or polyp. Those patients with an intramural fibroid had a tendency toward a higher failure rate (P 5 .10). Comparing the medications used to prepare the endometrium, patients treated with danazol had a trend toward a higher success rate (P 5 .09) than GnRHa or progestins. Conclusion: Preoperative findings can provide additional information with regard to endometrial ablation success. It appears that the trend toward failure is increased in patients with increased age, the diagnosis of an abnormal uterine cavity by ultrasound, and the presence of an intramural fibroid. Danazol administration, to prepare the endometrium, appears to offer a lower failure rate compared to GnRH agonists or progestins. Patients at greater risk of endometrial ablation failure based on age $41 years, abnormal intrauterine cavity, or the presence of intramural fibroids should be counseled about the higher failure rate and consider an alternative procedure such as hysterectomy.
Intraoperative blood loss and gestational age at pregnancy termination Dominic A. Marchiano, MD, Albert G. Thomas, MD, Robert Lapinski, PhD, Khousidai Balwan, BA, Jagruti Patel, BA Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Medical Center, New York, New York Objective: To establish the relationship of measured intraoperative blood loss to gestational age at pregnancy termination, and to determine which factors, if any, affect the risk of bleeding. Methods: A single-operator series of 363 consecutive women undergoing pregnancy termination between 5 and 24 weeks gestational age, as dated by ultrasound, was prospectively evaluated. All pregnancies under 13 weeks gestation were terminated by mechanical dilation and suction curettage without preoperative cervical ripening. All pregnancies between 13 and 24 weeks gestation were terminated by preoperative osmotic cervical dilation with laminaria tents and subsequent uterine evacuation by a combination of suction curettage, sharp curettage, and Bierer forceps extraction. All patients over 12 weeks gestation received a postoperative oxytocin infusion. Prim Care Update Ob/Gyns
Surgical Complications Risk Factor Age $65 years Medicaid/ no insurance (compared to private/ Medicare/HMO Academic medical center (compared to non-teaching hospital)
Medical Complications
Adjusted odds ratio
95% CI
Adjusted odds ratio
95% CI
1.73 1.36
1.58, 1.90 1.26, 1.47
4.54 1.62
4.16, 4.96 1.48, 1.77
1.86
1.74, 1.99
3.28
3.06, 3.52
Conclusions: Surgical complications of hysterectomy are more common, occur in younger women, and are associated with higher hospital charges than medical complications. Complication rates vary widely between hospitals, with teaching hospitals having the highest rates. This difference persists after adjustment for coded comorbidities. Possible explanations for the inability of multivariate analysis to explain the wide range in observed complication rates include 1) shortcomings in the available data or models, such as variability in coding practices between hospitals or variability in surgical difficulty between hospitals that is not captured with ICD-9-CM codes (eg, uterine size, cancer stage) and 2) variability in the quality of care between hospitals. Further research is needed to help determine the role of each of these explanations. Risk adjustment methods that use administrative data based on currently available coding standards are poor predictors of surgical complication rates after hysterectomy and should not be used to reach conclusions about quality of care.
Functional outcomes and satisfaction after abdominal hysterectomy Anne M. Weber, MD, Mark D. Walters, MD, Leslie R. Schover, PhD, James M. Church, MD, Marion R. Piedmonte, MA Cleveland Clinic Foundation, Cleveland, Ohio Objective: To compare urinary, lower gastrointestinal (GI), and sexual function and to describe patients’ expectations and satisfaction before and after hysterectomy. Methods: Forty-three women completed questionnaires before and about 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, lower GI, and sexual function were assessed. Women responded with “agree,” “disagree,” or “neutral” to statements about treatment options, the decision for hysterectomy, expectations about surgery and recovery, and satisfaction with their relationship with their doctor and their treatment. Comparisons were made between preoperative and postoperative responses. Statistical significance was accepted for P 5 .002 to account for multiple comparisons. Volume 5, Number 4, 1998
Results: The mean age was 45.4 6 6.7 years. Sixty percent were white, and 88% were premenopausal. The most common indication for hysterectomy was myomas in 76%. There were no statistically significant changes in urinary or bowel symptoms before and after hysterectomy with preoperative symptoms resolving in some women after surgery, and developing in others. Fewer women experienced abdominal bloating after hysterectomy than before. Frequency of intercourse and satisfaction with their sexual relationship did not change in the 34 sexually active women. The level of satisfaction with their treatment and their relationship with their doctor was very high. Conclusion: Women experience a high degree of satisfaction with treatment 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, GI, or sexual function occur frequently before and after surgery, but hysterectomy does not result in consistent changes.
Hysterectomy in a decade of change: more than a weighty matter John H. Kirk, MD, Beth Y. Karlan, MD, Patricia Cane, PhD, Kimberly Gregory, MD, MPH Department of Obstetrics & Gynecology, Cedars Sinai Medical Center & UCLA School of Medicine Objective: Hysterectomy is the second most common surgical procedure performed in the United States. Interest to decrease use of hysterectomy has focused on developing explicit criteria for surgery, peer review and second opinion, as well as changing reimbursement incentives. The purpose of this study is to describe the change in the number of hysterectomies, the indications for hysterectomies, and the histopathology of hysterectomy specimens over the last 10 years at one private, nonprofit, academic, community hospital that does not have a formal system for monitoring hysterectomy use. Methods: Retrospective study utilizing administrative data matched with pathology reports for nonmalignant hysterectomies performed in 1985, 1990, and 1995. Uterine weight and histopathologic diagnoses were recorded. When pathology reports were unavailable, cases were reviewed to determine if the indication was related to prolapse or urinary incontinence. Outcome measures included number of procedures performed, indications for procedures and uterine pathology (uterine weight, histopathology). We utilized the Cochran-Mantel-Haenszel x2 and the Kruskal-Wallis rank sum statistic (P , .05). Results: The number of hysterectomies declined from 631 in 1985 to 461 in 1995 (P 5 .007). The median uterine weight increased (P 5 .0007), and there was a decrease in the number
203
OTHER GYNECOLOGIC SURGERY of specimens with absent histopathology, decreasing from 6% in 1985 to 3% in 1995 (P 5 .013). This difference was explained by changes in the number of procedures performed on patients with private insurance and HMO reimbursement (P 5 .018). Conclusions: While the proportion of surgeries performed for specific indications did not change, the number of hysterectomies performed decreased, and there were fewer normal specimens.
Prediction of endometrial ablation success by preoperative findings William F. Ziegler, DO, Cynthia Sites, MD, Gary Badger, MS, Mousa Shamonki, BS Dept of OB/GYN and Biostatistics, University of Vermont College of Medicine, Burlington, Vermont Objective: To determine the influence of preoperative findings on the outcome of hysteroscopic endometrial ablation. Design: We performed a retrospective chart review of 80 women between the ages of 25 and 50 years who underwent an endometrial ablation for menorrhagia or menometrorrhagia from 1992 to 1996, through a university reproductive endocrinology clinic. Materials and Methods: All eligible patients had a detailed subjective history obtained for duration of dysmenorrhea (Dys) and menorrhagia or menometrorrhagia (Men). Each had a preoperative transvaginal pelvic ultrasound with documentation of the uterine cavity contour and if an intramural myoma was present. A gynecological examination was ascertained from the patients clinical record with regard to uterine size. A benign Papanicolaou smear within 1 year of surgery and a normal endometrial biopsy was required for inclusion. Those with evidence of carcinoma or menopausal symptoms were excluded. Each patient had endometrial preparation with either danazol, GnRHa, or progestin. All ablations were performed by the same surgeon with “rollerball” electrocautery. Those patients who required medical management or additional surgery to control their vaginal bleeding during follow-up were designated as ablation failures. The use of stepwise logistic regression with ablation outcome as the dependent measure was used along with univariate analyses via x2 and t test to compare successes and failures on specific characteristics. Results: The sample was divided into two groups, success (group 1) or failure (group 2), and were matched for gravity, parity, and uterine size. Between the two groups there were no significant differences in the duration of menorrhagia/ menometrorrhagia or dysmenorrhea. Additional therapy was required in 41% of the study group, designated as failures. The length of follow-up was 36 months for group 1 and 27.7 months for group 2. The results are summarized in the table below. 204
Group N Mean age (SD) Normal uterine cavity Intramural fibroid
1
2
P Value
47 (59%) 40 (65.23) 60% (28/47) 18% (8/44)
33 (41%) 41 (64.38) 39% (13/33) 34% (11/32)
.06 .07 .10
The difference in age between the two groups strongly suggests a tendency toward failure with increasing age (P 5 .06). The diagnosis of a normal uterine cavity preoperatively shows a trend for a successful outcome (P 5 .07) when compared with the presence of an intracavity lesion, fibroid, or polyp. Those patients with an intramural fibroid had a tendency toward a higher failure rate (P 5 .10). Comparing the medications used to prepare the endometrium, patients treated with danazol had a trend toward a higher success rate (P 5 .09) than GnRHa or progestins. Conclusion: Preoperative findings can provide additional information with regard to endometrial ablation success. It appears that the trend toward failure is increased in patients with increased age, the diagnosis of an abnormal uterine cavity by ultrasound, and the presence of an intramural fibroid. Danazol administration, to prepare the endometrium, appears to offer a lower failure rate compared to GnRH agonists or progestins. Patients at greater risk of endometrial ablation failure based on age $41 years, abnormal intrauterine cavity, or the presence of intramural fibroids should be counseled about the higher failure rate and consider an alternative procedure such as hysterectomy.
Intraoperative blood loss and gestational age at pregnancy termination Dominic A. Marchiano, MD, Albert G. Thomas, MD, Robert Lapinski, PhD, Khousidai Balwan, BA, Jagruti Patel, BA Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Medical Center, New York, New York Objective: To establish the relationship of measured intraoperative blood loss to gestational age at pregnancy termination, and to determine which factors, if any, affect the risk of bleeding. Methods: A single-operator series of 363 consecutive women undergoing pregnancy termination between 5 and 24 weeks gestational age, as dated by ultrasound, was prospectively evaluated. All pregnancies under 13 weeks gestation were terminated by mechanical dilation and suction curettage without preoperative cervical ripening. All pregnancies between 13 and 24 weeks gestation were terminated by preoperative osmotic cervical dilation with laminaria tents and subsequent uterine evacuation by a combination of suction curettage, sharp curettage, and Bierer forceps extraction. All patients over 12 weeks gestation received a postoperative oxytocin infusion. Prim Care Update Ob/Gyns