CLINICAL INDICATIONS FOR HYSTERECTOMY ROUTE - PATIENT CHARACTERISTICSOR PHYSICIAN PREFERENCE

OBJECTIVES: Our purpose was to compare the indications, characteristic s, surgical management, and outcomes of patients undergoing total abdo minal hysterectomy, total vaginal hysterectomy, and laparoscopically a ssisted vaginal hysterectomy and to assess whether patients who underw ent abdominal hysterectomy might have been candidates for laparoscopic ally assisted vaginal hysterectomy and whether patients who underwent total abdominal hysterectomy or laparoscopically assisted vaginal hyst erectomy might have been candidates for total vaginal hysterectomy. ST UDY DESIGN: The hospital charts of 502 women who underwent elective in patient hysterectomy at a single large general hospital between Januar y 1992 and November 1993 were abstracted retrospectively by use of a s tructured data abstraction instrument. The study included patients ope rated on by 16 different experienced gynecologists. Data were collecte d regarding patient demographic characteristics, clinical history and preoperative physical examination, indications for surgery, route of h ysterectomy, intraoperative findings, pathologic study results, and ou tcomes in the immediate postoperative hospitalization period. RESULTS: Patient age, race, weight, parity, and previous surgical history were significantly associated with hysterectomy type. Although no nullipar ous patients and no patients with a uterine size estimated preoperativ ely to be >12 weeks of gestation underwent total vaginal hysterectomy, 16.6% and 30.6% of laparoscopically assisted vaginal hysterectomy pat ients had these characteristics, respectively. A total of 6.6% of tota l abdominal hysterectomy cases and 15.7% of laparoscopically assisted vaginal hysterectomy cases lacked an obvious justification for an abdo minal procedure. On average, surgical time was 23 minutes longer for l aparoscopically assisted vaginal hysterectomy than for total abdominal hysterectomy and 30 minutes longer for total abdominal hysterectomy t han for total vaginal hysterectomy. When uterine size or configuration impaired access to uterine vessels, laparoscopically assisted vaginal hysterectomy was difficult to perform. Postoperative morbidity was si milar across the three procedures, but average length of hospital stay was 2.8 days, 3.5 days, and 4.4 days for laparoscopically assisted va ginal hysterectomy total vaginal hysterectomy, and total abdominal hys terectomy, respectively. CONCLUSIONS: Although there are some consiste nt and statistically significant differences in the characteristics of patients undergoing total abdominal hysterectomy versus laparoscopica lly assisted vaginal hysterectomy versus total vaginal hysterectomy la paroscopically assisted vaginal hysterectomy is enabling many patients to avoid total abdominal hysterectomy. However, many patients undergo ing total abdominal hysterectomy and laparoscopically assisted vaginal hysterectomy could probably undergo total vaginal hysterectomy instea d. Clinical outcomes were similar regardless of type of hysterectomy p erformed. Practice style and personal preference of the surgeon thus m ay be playing a significant role in selection of hysterectomy type. La paroscopically assisted vaginal hysterectomy becomes technically diffi cult acid conversion to total abdominal hysterectomy is more frequent when uterine size or configuration impairs access to uterine vessels.