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Gynecologic surgeons worldwide continue to use the abdominal approach for a large majority of hysterectomies that could be performed vaginally despite well-documented evidence that vaginal hysterectomy has distinct health and economic benefits in terms of fewer complications, better postoperative quality-of-life outcomes, and reduced hospital charges. Because abdominal hysterectomy is associated with less favorable medical outcomes, evidence supports its use only when documented pathologic conditions preclude the vaginal route.1,2,3,4 However, some surgeons remain reluctant to change their practice patterns, and continue to select the abdominal route for most hysterectomies without documenting that the vaginal route is contraindicated. The algorithm in Figure15 offers gynecologic surgeons a structured approach for selecting the appropriate surgical technique. Using a formal decision process to determine the route of hysterectomy has shown that evidence-based guidelines could potentially save 1.2 million dollars for every 1000 hysterectomies performed, would free up 1020 patient bed days, and reduce complications by 20%. Adherence to these guidelines should enable physicians to perform 80% of hysterectomies via the vaginal route, dramatically reducing the current 3:1 abdominal/vaginal ratio.6 Because we have neglected to adopt evidence-based formal practice guidelines for hysterectomy surgeons all too often choose a route of hysterectomy based on their own personal preference justifying the appropriateness of their choice. Thus surgeons often select vaginal or abdominal hysterectomy for similar conditions without determining the evidence supporting one procedure over the another. The American College of Obstetricians and Gynecologists (ACOG) tentatively addressed this problem by issuing a statement that vaginal hysterectomy is best performed in women with mobile uteri no larger than 12 weeks’ gestational size (~280 g). ACOG continued by acknowledging by committee opinion that the choice of hysterectomy approach should be based on the surgical indication, the patient’s anatomic condition, data supporting the chosen approach, informed patient preference, and the surgeon’s expertise and training 5 Figure 2). Furthermore, ACOG acknowledges that the desire ratio for cases performed vaginally versus abdominally should be 70% by the vaginal route and 30% abdominally. 7 Unfortunately, these recommendations have never been subjected to critical review and current evidence suggest that a physician’s expertise and training may be the only consideration in selecting the route of hysterectomy. This has resulted in a current ratio obtained from NHDS in 1999 of 63.8% of hysterectomies performed abdominally and 23.6% vaginally. 8 Historically, abdominal hysterectomy is accepted to be appropriate for more serious diseases that necessitate this approach. However, traditional teaching predisposes surgeons to select the abdominal route despite pathologic indications. Further compounding the problem many of the traditional indications for selecting an abdominal hysterectomy were never subjected to vigorous review and in many cases have been shown to be invalid (figure 2).9 Performing abdominal hysterectomies for less serious conditions subject women to greater risks of complications, longer recuperation and poorer postoperative quality of life outcomes. Vaginal hysterectomy has been regarded as contraindicated when the vaginal route is presumed to be inaccessible or when more serious pathologic conditions such endometriosis, pelvic adhesive disease, adnexal pathology, chronic pelvic pain, and chronic pelvic inflammatory disease are thought to exist. In addition, many surgeons hesitate to perform vaginal hysterectomy in nulliparous women, in women who have had previous pelvic surgery (including one or more cesarean sections), in those with a moderately enlarged uterus, or when oophorectomy is to be performed concurrently. Traditional indications for abdominal and contraindications for vaginal hysterectomy must be reevaluated on the basis of currently available data. For example, for many years the literature has shown that the ovaries can be removed transvaginally in most women undergoing vaginal hysterectomy. In numerous studies, prophylactic vaginal oophorectomy was successfully performed in 95% of patients. Ovaries that descend into the vagina when the infundibulopelvic ligament is stretched are usually visible and accessible for transvaginal removal, even if the descent is partial. In 966 women undergoing vaginal hysterectomy it was found that the ovaries were or could have been removed vaginally without laparoscopic assistance in more than 99%.10 The common belief that the ovaries must be removed by the abdominal route or via operative laparoscopy is a myth that can no longer be tolerated if no valid contraindications to transvaginal ovarian removal can be documented. The selection of abdominal hysterectomy for more serious pathologic conditions has been a de facto guideline that has gone largely unchallenged. Surgeons do not always select the route and method of hysterectomy based on (documentation of the severity of the pathology. Rather, mere suspicion of pathology frequently dictates the approach used. Although information in the gynecologic literature comparing the preoperative diagnosis of hysterectomy with pathologic results is sparse, there is sufficient evidence that the presumptive preoperative diagnosis is often inaccurate, representing a diagnosis treatment discrepancy. Continued reliance on abdominal hysterectomy despite well-documented studies disputing its efficacy has been attributed to several nonclinical factors that create a discrepancy between the state of current practice and our knowledge regarding the best standard of care. As noted earlier, evidence-based formal practice guidelines have not been adopted that clearly identify appropriate candidates for abdominal hysterectomy, vaginal hysterectomy, or laparoscopic assistance to complete a vaginal hysterectomy. Insufficient training and experience in vaginal and laparoscopic techniques have also been cited. Misperceptions have contributed further to the confusion. Many surgeons simply feel more comfortable with the abdominal route in nulliparous women, when the uterus is enlarged, in the absence of uterine prolapse, or when oophorectomy is required. Physician practice styles favoring a single route or method have been allowed to go unchallenged despite the pressure for more cost-effective health care. This bias can no longer be accepted.11 Several outcome-based studies show that vaginal hysterectomy can be successfully performed in approximately 77% to 94% of patients with benign disease by using a formal decision-making process to determine the route of hysterectomy.2,3,4 Three critical questions must be answered before selecting the surgical route of hysterectomy for patients with benign disease. 1.Can the uterus be removed transvaginally? 2.Is the pathology confined to the uterus or does it extend beyond the confines of the uterus? 3.Is laparoscopic assistance required to facilitate vaginal removal of the uterus? Transvaginal Accessibility A major factor in determining the route of hysterectomy is transvaginal accessibility of the uterus. Inadequate accessibility sustaining from a narrowed vagina at the vaginal apex makes vaginal hysterectomy technically challenging and may contraindicate vaginal hysterectomy, especially by surgeons less experienced in this procedure. Two factors limit accessibility: an undesended and immobile uterus and a vagina narrower than 2 fingerbreadths, especially at the apex. Gynecologic surgeons should be alert for these indicators when examining patients. A narrowed pubic arch, frequently suggested as a contraindication to vaginal hysterectomy has never been proven to be a deterrent to the vaginal route. Nulliparity is not an absolute contraindication to vaginal hysterectomy. Although access to the vaginal vault may be restricted in some nulliparous women, inaccessibility cannot be assumed in all cases. In fact, there is no evidence in the literature to support the widely held belief that nulliparity makes vaginal hysterectomy difficult. If accessibility appears adequate, the women may be a candidate for a vaginal hysterectomy with or without laparoscopic assistance. Uterine Size Gynecologic surgeons have long considered an enlarged uterus a contraindication to vaginal hysterectomy, but the term enlarged has not been clearly defined. A normal-size uterus weighs approximately 70 to 125g. ACOG and other investigators assert that vaginal hysterectomy is indicated in women with mobile uteri no larger than 12 weeks’ gestational size (~280g), suggesting that uteri greater than 280g are appropriately performed by the abdominal route.12 Coring, bivalving, and morcellation are well-accepted methods of reducing an enlarged uterus so that it can be removed transvaginally. However, studies show that in reality between 80% and 90% of all uteri removed for various indications weigh 280g or less and do not require reduction technique for vaginal removal. Several investigators reported using pharmacologic agents to reduce the size of the uterus preoperatively when necessary. In clinical studies patients with pretreatment uterine sizes ranging from 14 to 18 weeks’ gestational size, the administration of gonadotropin-releasing hormone analogues reduced the size of symptomatic uterine leiomyomata by 30% to 50% and decreased uterine volume by approximately one third before hysterectomy in patients with enlarged uteri who would have been candidates for abdominal hysterectomy. The size of the uterus in vivo usually can be measured by simple physical examination. If there is still a question about uterine size, transvaginal ultrasound is another option. An algebraic formula is used to determine the uterine size, expressed in weights and measurements. By multiplying the three dimensions of the uterus in centimeters (length X width X anteroposterior diameter at the fundus) by 0.52, physicians can estimate the mass of the uterus in grams in order to obtain a more accurate preoperative estimate of uterine size.13 Example: 6cm X 6cm X 8cm X 0.52 = 149g.) Preoperative documentation of uterine size in vivo can help to prevent abdominal hysterectomy being selected unecessarily. Extent of Pathology Determining whether the pathology is confined to or extends beyond the confines of the uterus is critical to selecting the most appropriate route of hysterectomy. According to the algorithm, a vaginal hysterectomy is indicated when pathology is confined to the uterus and the uterus is <280g. When the preoperative diagnosis suggests that the pathologic condition extends beyond the confines of the uterus, laparoscopic evaluation can help determine the severity of the condition before deciding whether to remove the uterus via the vaginal or abdominal route. Traditionally, gynecologic surgeons used the results of the history, physical examination, and imaging techniques, such as ultrasound and x-ray studies, to determine whether the pathology extended beyond the uterus. However, several investigators7,8 have proved that these techniques are not sufficiently accurate to adequately document the severity of those conditions, especially endometriosis, adnexal pathology, chronic pelvic pain, and pelvic inflammatory disease. Such preoperative examinations are not sufficiently accurate to allow us to make precise surgical decisions. When surgeons based their decision to perform an abdominal hysterectomy on the clinical history and pelvic examination without further intraoperative documentation of the severity of the patient’s condition, the surgical findings often did not support the selection of the abdominal route, again a diagnosis/treatment discrepancy. Not only is the laparoscope useful for accurately assessing the extent and characteristics of the disease, it is also valuable in determining the mobility of the uterus and adnexal structures. Laparoscopic examination provides a panoramic view of the pelvis and allows the surgeon to directly examine the degree of the pathology and note the presence of any conditions that might contraindicate vaginal hysterectomy. The laparoscope can prove a valuable tool for reassessing the severity of the disease process. Several investigators use a laparoscopic scoring system9,13 determine numerically the severity of the disease based on uterine size, adnexal accessibility, and the presence or absence of adhesions, endometriosis, and other abnormalities. Three critical variables inherent in this scoring system should be assessed during the laparoscopic examination: accessibility of the cul-de-sac, severity of adhesions, and severity of endometriosis. If the extrauterine pathology is absent or minimal on laparoscopic examination, a vaginal hysterectomy is indicated. Despite current belief, previous pelvic surgery, including cesarean section, does not preclude a vaginal hysterectomy unless extensive adhesions are observed during laparoscopy as limiting accessibility, particularly to the anterior abdominal wall. Patients with minimal pathology have few or no adhesions, little or no endometriosis, and an accessible cul-se-sac. If laparoscopic assessment reveals moderate pathology, including moderate adhesions or endometriosis but an accessible cul-de-sac, it is necessary to determine whether the impediments can be removed laparoscopically before proceeding to a vaginal hysterectomy. If severe endometriosis is present and the cul-de-sac is obliterated by severe adhesions, an abdominal hysterectomy is indicated. Laparoscopically assisted vaginal hysterectomy has compounded the decision-making dilemma in recent years. Although ACOG acknowledges that laparoscopically assisted vaginal hysterectomy is an acceptable alternative to abdominal hysterectomy, many surgeons continue to question how much laparoscopic assistance is appropriate before removing the uterus transvaginally.14 If operative laparoscopy is indicated, it is beneficial to convert to a vaginal hysterectomy as early as possible in the procedure, for example, after adhesiolysis. Several studies have suggested that nothing is gained by continuing the laparoscopic dissection once a vaginal hysterectomy can be performed safely, because it does little more than prolong surgery, increase costs, and increase the risk of morbidity. Although laparoscopic surgeons have proposed laparoscopically assisted vaginal hysterectomy as a replacement for abdominal and vaginal hysterectomy, its advantages over vaginal hysterectomy have not been documented in this population when there are no contraindications to the vaginal approach.15 Conclusion If the goal of gynecologic surgeons is to select the optimal route of hysterectomy based on the best medical outcomes, the clinical factors that are valid indicators of the route to be selected must be identified. Medical standards in today’s managed care environment rely on evidence-based practice guidelines that are defined by outcomes rather than subjective criteria, such as physician comfort, preference, or experience. The marked variation in health care for alternative hysterectomy procedures will likely persist until organizations such as the National Institute of Clinical Practice in the United Kingdom, RCOG and ACOG address the issue of best practice standards and make appropriate recommendations.16 Gynecologic surgeons can no longer continue to select the route of hysterectomy on their training or expertise and preference. The adoption of evidence-based practice guidelines offer the best route of hysterectomy to be chosen as each step of the algorithm requires an evidence demanding question that needs an appropriate answer before selecting the route of hysterectomy. This removes the possible inappropriate selection of a particular route of hysterectomy based upon a surgeon’s lack of expertise and preference Gynecologic Surgeons must clearly demonstrate that the route of hysterectomy they choose not only benefits the patient medically but also represents a wise use of health care dollars. There is no question that abdominal hysterectomy should be performed in cases of documented serious disease; however, this route should not be misused as now is prevalent. Developing clinical guidelines based on accurate physical findings is the first step in ensuring that women will undergo the most appropriate route of hysterectomy that is cost-effective and meets the standard of quality care.6,17,18 The potential impact of the physician’s decision to select the vaginal approach may be enormous in terms of decreased hospital stay, lower hospital charges, and reduced complications. Physician accountability is at stake. Increasingly as become more knowledgeable there are demanding hysterectomies be performed vaginally. No woman prefers the discomfort of an abdominal incision and as more women become aware of their options offered by the hysterectomy guidelines, they will surely question whether their physician is influenced by his training, preference and sometimes his lack of experience in offering the best surgical options, thus informed consent will be a further issue. Without adequate documentation and fair presentation of the scientific evidence, a truly informed consent cannot be obtained. Current practice standards shortchange the physician as well as the patients. Insurers typically pay more for abdominal hysterectomies based on the assumption that these patients have more serious pathology when, in fact, they are often performed for the same indications. Vaginal hysterectomy patients, on the other hand, are typically discharged from the hospital in 1 day rather than the typical 3 days permitted abdominal hysterectomy patients regardless of the pathologic indications. As gynecologic surgeons our responsibility is to provide the best surgical care proven by rigorous review of the evidence. We must decide whether we are prepared to offer and deliver this type of care. The future surgical relationships with our patients will depend whether we make our surgical decisions based on evidence or because of our lack of surgical expertise. The choice is ours to make. References Diker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The Collaborative Review of Sterilization. Am J Obstet Gynecol. 1982;144:841-846. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet Gynecol 1995;85:18-23. Richardson RE, Bournas N, Magos A. Is laparoscopic hysterectomy a waste of time? Lancet. 1995;345:36-41 Querleu D, Cosson M, Paramentier D, Debodinance P. The impact of laparoscopic surgery on vaginal hysterectomy. Gynecol Endosc. 1993;2:89-91. National Guideline Clearinghouse. Guideline synthesis: Guidelines for determining the route of hysterectomy for benign conditions. In: National Guidelines Clearinghouse (NGC) website. Rockville (MD);[cited 2000 Mar 1] http://www.guidelines.gov. Kovac SR. Decision-directed hysterectomy: a possible approach to improve medical and economic outcomes. Int. J. Gynaecol Obstet. 2000;71(2):159-69. Quality assurance in obstetrics and gynecology. Washington, DC. American College of Obstetrician and Gynecologists, 1989. National Center for Health Statistics. National Hospital Discharge Summery, 1997. Public use data filed and documented on CD-ROM. KovacSR, Cruikshank SH, Retto HF:Laparoscopy-assisted vaginal Hysterectomy. J Gynecol Surg 1990;6:185-93. Kovac SR, Cruikshank SH: Guidelines to determine the route of oophorectomy with Hysterectomy. Am J Obstet Gynecol. 1996;185:1483-8. Kovac SR, Abdominal versus vagianl hysterectomy: A statistical Model for Determining Physician Decision Making and Patient Outcome. Medical Decision Making. 1991;11:19-28 American College of Obstetricians and Gynecologists. Precis IV: An Update in Obstetrics and Gynecology. Washington, DC: The College;1990:page 197. Kung F, Chang S. The relationship between ultrasinic volume and actual weight of pathologic uterus. Gynecol Obster Invest. 1996;42:35-38. American College of Obstetricians and Gynecologists. Operative laparoscopy. ACOG EducationalBulletin..Number 239, August 1997. Kovac SR. Guidelines to determine the role of laparoscopy assisted vaginal hysterectomy. Am J Obstet Gynecol 1998;178:1257-63. Davies A, Magos A. The hysterectomy lottery. J Obstet Gynaecol 2001;21:166-170. Kovac SR. Hysterectomy outcomes in Patients with Similar Indications. Obstet Gynecol 2000;95:787-93. Kovac SR: Guidelines to determine the route of hysterectomy. Obstet Gynecol 1995;85:18-23 Figure 1. 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