Severe complications of hysterectomy: the VALUE study

Abstract

Objectives To model the determinants of serious operative and post-operative complications of hysterectomy and their potential risk factors. Design A prospective cohort of women undergoing hysterectomies for benign indications in 1994/1995, with a six-week postsurgery follow up. Population and setting A total of 37,512 women from 276 NHS and 145 private hospitals in England, Wales and Northern Ireland, originally recruited to compare the outcomes of endometrial destruction with those of hysterectomy. Methods Gynaecologists reported hysterectomies for non-malignant indications carried out during a 12-month period beginning in October 1994 and follow up data were obtained at outpatient follow up six weeks postsurgery. Odds ratios of severe complications by indication and method, adjusting for measured intrinsic risk factors, were calculated. Main outcome measures Severe operative and post-operative complications.Results Severe operative complications occurred in 3%. The risk decreased with age and increased with greater parity and history of serious illness. Women with symptomatic fibroids (4.4%, 95% CI 3.9 -4.9) experienced more complications than women with dysfunctional uterine bleeding (3.6%, 3.2 -3.8), adjusted odds ratio (OR) ¼ 1.3 (95% CI 1.1 -1.6). Laparoscopic procedures (6.1%) doubled the risk of operative complications of abdominal hysterectomy (3.6%) (adjusted OR ¼ 1.9, 1.5-2.5). Post-operative complications occurred in around 1% of women, with a slight decrease with increasing age, and the strongest risk factor was a history of operative complications. Relative to dysfunctional uterine bleeding (1.0%), a higher risk for fibroids (1.2%) persisted after adjustments (RR ¼ 1.5, 1.1-2.0). Both vaginal (1.2%) and laparoscopic (1.7%) techniques had significantly higher adjusted risks than abdominal operations (0.9%), RR ¼ 1.4 (1.0 -1.9) and RR ¼ 1.6 (1.0 -2.7). There were no operative deaths; 14 women died within the six-week postsurgery (a crude mortality rate of 3.8/1000, 2.5 -6.4). Conclusions Hysterectomy is a common, routine surgery with comparatively rare serious complications.However, younger women, women with more vascular pelvises, who undergo hysterectomy, especially laparoscopically assisted vaginal surgery for symptomatic fibroids, are at most risk of experiencing severe complications both operatively and post-operatively. Therefore, a less invasive alternative treatment for symptomatic fibroids could particularly benefit this group of women, while less invasive treatments for dysfunctional uterine bleeding, such as various methods of endometrial ablations or resections, would need to meet the current low levels of clinical complications in order to replace hysterectomy.

Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroids: an updated decision analysis following the 2014 Food and Drug Administration safety communications

“…That there was not a major swing in the conclusion of the model with integration of the expanded and improved data adds credibility to our original model. Mortality from the procedure itself (LH vs AH) was one of the most challenging clinical outcomes to assess in our original decision analysis, but we identified a newly published study 22 that provided very similar numbers to the original inputs, 23–25 again suggesting our model is robust.…”

“…25 B , Sensitivity analysis 1: LH mortality 0.0.00096, AH mortality 0.00038. 23–24 C , Sensitivity analysis 2: LH mortality 0.00013, AH mortality 0.00034. 22 …”

Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroid tumors in premenopausal women: a decision analysis

“…infection, venous thromboembolism) were different from modern practice, 11,12 estimates of 0.00012 (laparoscopic hysterectomy) and 0.00032 (abdominal hysterectomy) were derived from three larger and more recent series. 13-15 …”

Safe total intrafascial laparoscopic (TAIL™) hysterectomy: a prospective cohort study

“…The most dreaded complication—the risk of ureteric lesions—has repeatedly been shown to be increased applying the laparoscopic hysterectomy technique as compared to abdominal procedures [1, 2, 16, 21]. In contrast, we demonstrate that the laparoscopic approach is associated with a very low incidence of these complications discussed.…”