Radical hysterectomy: past, present, and future

After an analysis of 3,441 radical hysterectomies performed in our department, we found, after modification of the operative technique in 1983, the more lateral the excision the less the recurrence rate. The recurrence rate for Stage 1b-2a and Stage 2b patients comparing the years before 1983 to the years after decreased to 12.4% from 15.7% (158/1,006 vs 268/2,163; p = 0.009) in Stage 1b-2a and 24.6% from 55.8% (38/68 vs 47/191; p = 0.0007) in Stage 2b, respectively. With the modern trend of aspiring for an easier lifestyle, most physicians practice earlier. Therefore only very few physicians study radical hysterectomy. As the skill of surgery needs a longer period of education and training, it may only interest physicians who work with medical professionals as part of a team at a medical center. In the future, we should provide gynecological residents not only with a training program using the classic textbooks, but also with different points of view on changes and developments in radical hysterectomy. We hope to promote an attitude of offering patients access to different choices and opportunities of therapy. Radical hysterectomy is in fact a treatment option for patients with bulky cervical lesions and Stage 2b in particular.

Extent of radical hysterectomy: evolving emphasis

OBJECTIVE

As with other oncologic operations, the indications for and the technique of radical hysterectomy for cervical cancer has changed considerably since its initial conception in the late 19th century. This paper reviews the evolution of concepts concerning the extent of radical hysterectomy for cervical cancer.

METHODS

A Medline literature search was performed through looking for articles published in the English language that related to radical hysterectomy for cervical cancer. Specific subjects that were searched included technique, morbidity, and histopathologic assessment of the parametria.

RESULTS

Initial emphasis on local control and potential long-term survival gradually shifted to reduction of mortality and serious morbidity. Early refinements directed attention to the regional lymph nodes, definition of prognostic factors, and determination of the population of patients best suited for the operation. During the mid to late 20th century, a better understanding of regional and local prognostic factors helped clarify the role of adjuvant treatment following radical hysterectomy. By the mid 20th century, the mortality and serious morbidity rates had fallen substantially, and attention turned to reduction of other types of morbidity, especially urinary bladder voiding dysfunction. Reduction of much of the serious morbidity (urinary fistulas) and voiding dysfunction has been related to modifications of the extent of radical hysterectomy. Specific nerve-sparing techniques now have been described. However, maintaining full radicality continues to be emphasized at some centers.

CONCLUSION

The current primary operative approaches to stage 1B cervical cancer include full radical hysterectomy, modified radical hysterectomy followed by adjuvant therapy in selected patients, radical hysterectomy with nerve-sparing, and individualization of surgical management. Studies are needed which further elucidate the significance of parametrial micrometastases, further define and refine broadly feasible nerve-sparing techniques, and more accurately preoperatively identify low and high risk cervical tumors. Optimally, these studies will remove adjuvant treatment as a confounding variable.

Ovarian cancer surgery in Maryland: volume-based access to care

PURPOSE

To characterize the patterns of primary surgical care for ovarian cancer in a statewide population according to annual surgeon and hospital case volume.

METHODS

The Maryland hospital discharge database was accessed for annual surgeon and hospital ovarian cancer case volume for the time intervals: 1990-1992, 1993-1995, 1996-98, and 1999-2000. Annual surgeon case volume was categorized as low (</=4), intermediate (5-9), or high (>/=10). Annual hospital case volume was categorized as low (</=9), intermediate (10-19), or high (>/=20). Logistic regression models were used to evaluate for significant trends in case volume distribution over time and factors associated with access to high-volume care.

RESULTS

Overall, 2417 cases were performed by 531 surgeons at 49 hospitals. The distribution according to annual surgeon case volume was low (56.3%), intermediate (9.2%), and high (34.5%). Between 1993 and 2000, there was no significant increase in the proportion of cases performed by high-volume surgeons (OR = 1.03, 95% CI = 0.81-1.33, P = 0.79). Access to high-volume surgeons was positively associated with care at high-volume hospitals and negatively associated with residence >/=50 miles from a high-volume hospital. The overall hospital volume case distribution was low (49.6%), intermediate (27.6%), and high (22.8%). There was a statistically significant decrease in access to high-volume hospitals between 1990 and 1998 (OR = 0.39, 95% CI = 0.30-0.50, P < 0.0001).

CONCLUSION

A large proportion of primary ovarian cancer surgeries are performed by low-volume surgeons at low-volume hospitals. In light of positive volume-outcomes data for malignancies treated with technically complex operative procedures, increased efforts to concentrate the surgical care of women with ovarian cancer are warranted. Condensed abstract. A large proportion of primary ovarian cancer surgeries are performed by low-volume surgeons at low-volume hospitals. In light of positive volume-outcomes data for malignancies treated with technically complex operative procedures, increased efforts to concentrate the surgical care of women with ovarian cancer are warranted.

Hysterectomy and endometrial ablation in New South Wales, 1981 to 1999-2000

OBJECTIVE

To examine the trends in hysterectomy in New South Wales (NSW) from 1981 to 1999-2000 and the impact of endometrial ablation.

DATA

Computerised discharge summaries from private and public hospitals for the years 1981, 1991, 1994-1995 and 1999-2000 obtained from the NSW Health Department. All records listing hysterectomy in women over the age of 20 in each period were selected and those listing endometrial ablation since 1991 were also selected. Operative procedure, diagnosis, hospital type, length of stay and demographic data were recorded. Annual figures since 1988-1989 for hysterectomy and ablation were also obtained.

FINDINGS

Initially it appeared that the introduction of endometrial ablation might reduce hysterectomy rates, but the combined rate of hysterectomy and endometrial ablation continued to rise to a peak in 1992-1993 and has declined since. The hysterectomy rate in 1999-2000 was lower than in 1981. There has been a marked shift from abdominal to vaginal hysterectomy, with an increase in laparoscopically assisted operations. Overall, the mean age at operation has been rising, although the mean age for vaginal hysterectomy has fallen. The shift to private hospitals and reduction in hospital stay have continued.

CONCLUSION

The trends are consistent with the increased use of laparoscopic and ablation techniques, improvements in hormonal contraceptive use, and better access to abortion, which have facilitated women's decisions to postpone their births and to conserve their childbearing to older ages. Further development of these techniques will have an impact on gynaecological training and practice in the next decade.

Changes in the demographics and perioperative care of stage IA(2)/IB(1) cervical cancer over the past 16 years

OBJECTIVES

The aim of this study was to determine whether there have been any significant changes in the demographics and perioperative care of FIGO stage IA(2)/IB(1) cervical cancer over the past 16 years and, if so, to quantify them.

METHODS

Since July 1984, all patients with FIGO stage IA(2)/IB(1) cervical cancer undergoing radical surgery by members of our division have been entered into a prospective database. Selection for surgery has been unchanged over the past 16 years. Since March 1994 and November 1996, one surgeon has performed radical vaginal trachelectomy and laparoscopic assisted radical vaginal hysterectomy, respectively. Statistical analysis used Spearman's correlation analysis, the proportional hazards regression model of Cox, and the Mantel-Hanzel test was performed. Due to the number of statistical analyses, statistical significance was defined as P < 0.01.

RESULTS

Eight hundred sixty-four patients have undergone radical surgery (784 radical hysterectomy, 42 radical vaginal trachelectomy, 32 radical vaginal hysterectomy, 6 radical abdominal trachelectomy) for FIGO stage IA(2)/IB(1) carcinoma of the cervix by members of our division since 1984. There have been no changes in the median age (40 years), tumor size (2.0 cm), incidence of capillary lymphatic space involvement (47%), or positive pelvic lymph nodes (6%) over the past 16 years. The median Quetelet index (24.6), depth of tumor invasion (squamous cell carcinomas only) (6.0 mm), and proportion of patients with comorbid conditions (17%) have increased over time (P = 0.001, P = 0.003, and P < 0.001, respectively). Pathologically, there has been an increase in the proportion of adenocarcinomas (28%) and a decrease in the proportion of grade 3 tumors (28%) (P < 0.001 and P < 0.001, respectively). The median operating time (2.8 h), hospital stay (7.0 days), blood loss (600 cc), allogeneic blood transfusion (23%), postoperative infections (13%), and noninfectious complications (6%) have all decreased (P < 0.001, P < 0.001, P < 0.001, P < 0.001, P < 0.001, and P = 0.002, respectively). There has been no change in the incidence of positive surgical margins (3%), adjuvant radiation (13%), or recurrence-free survival (2 and 5 years, 94 and 90%, respectively) after a median follow-up of 45 months.

CONCLUSION

Despite no substantive changes in the selection criteria for surgery and the small time interval studied (16 years), almost all indices of operative and postoperative morbidity analyzed have decreased significantly. These changes have occurred without an increase in the use of adjuvant radiation or decrease in recurrence-free survival. Although little progress has been made in the cure rates associated with surgical management of FIGO stage IA(2)/IB(1) cervical cancer during this time interval, it appears that the morbidity of surgery has decreased.

Hysterectomy prevalence and adjusted cervical and uterine cancer rates in England and Wales

OBJECTIVE

To present recent trends in cervical and uterine cancer adjusted for true population at risk, using accurate estimates of the prevalence of hysterectomy where the cervix has been removed or not. To describe trends and projections of hysterectomy incidence and prevalence with and without cervix removal.

DESIGN

Collation of available NHS and private sector information.

SETTING

England and Wales.

SAMPLE

NHS operations from Hospital Inpatient Enquiry, Hospital Episode Statistics and Hospital Activity Analysis for England and Wales. Private sector data from surveys with up to 97% coverage. METHODS AND MAIN OUTCOME: Measures NHS data by 5-year age group, year and operation type were collated for 1961-1995. non-NHS operations for 1981, 1986, and 1992/3 were back-projected. Hysterectomy incidence rates, 1961-95, were back-projected to estimate prevalence rates by accumulation. True populations at risk of disease and hysterectomy were calculated by applying one minus the relevant hysterectomy prevalence rates to the population by age group and year.

RESULTS

When based on the true population at risk, the age standardised cervical cancer incidence rate in 1992 was 14.4 per 100,000, compared with 12.6 when based on the all women population estimate. Incidence rates for earlier years were also affected, but there was no important effect on the rate of change over time. Absolute changes for uterine cancer are greater because the true population at risk is proportionally smaller particularly at the older ages, but there are again no major effects on the rate of change. By 1995 2.3 million women in England and Wales were without a uterus, with a peak prevalence of 21.3% in the age group 55-59. Projections based on 1995 incidence rates show hysterectomy prevalence for the screened age groups, 25-64, will now fall. Subtotal hysterectomy is 3.5% of operations and increasing.

CONCLUSIONS

True populations at risk must be used to assess the impact of screening if further reductions in cervix cancer incidence rates are not to be masked. It is essential to monitor hysterectomy by type, as subtotal hysterectomy is becoming more common. Hysterectomy incidence may have peaked. Hysterectomy prevalence in England and Wales may not be as high as would be estimated from some regional studies.

Hysterectomy on benign indication in Denmark 1988-1998. A register based trend analysis

BACKGROUND

The aims of the study were to describe the trends in Danish hysterectomy rates from 1988 to 1998 for operations done on benign indication.

METHODS

Data from all women (n=67,096) undergoing hysterectomy from 1988 to 1998 were obtained from the Danish National Patient Register. Data on the female population distribution were obtained from the Danish National Population Register.

RESULTS

During the last 11 years the incidence rate of hysterectomy performed for benign diseases has been stable. However, the rate of women treated surgically for benign diseases of the uterus has increased by 14%. During the study period the number of total abdominal hysterectomies has decreased by 38%, the number of subtotal abdominal hysterectomies has increased by 458%, the number of vaginal hysterectomies has increased by 107% and two new methods of surgical treatment for benign diseases of the uterus have been introduced. Abdominal hysterectomy still accounts for 80% of the total number of hysterectomies performed in Denmark in 1998. The age distribution for all hysterectomies has changed, from a maximum of 36-45 years in 1988 to 46-55 years in 1998. The age maximum for abdominal hysterectomy corresponds to that of all hysterectomies. For vaginal hysterectomy the age maximum is 56 years or older, while it is 36-45 years for laparoscopic hysterectomy.

CONCLUSIONS

The incidence rate of hysterectomy was stable during the study period and the age distribution for all hysterectomies has changed. The study showed a change in the choice of surgical methods, although no evidence supports this practice.

Emergency peripartum hysterectomy

BACKGROUND

Emergency hysterectomy in obstetric practice is generally performed in the setting of life-threatening situations.

OBJECTIVE

To review cases of peripartum hysterectomy in respect of indications, risk factors and complications.

DESIGN

A retrospective study.

SETTING

King Edward VIII Hospital, Durban.

SUBJECTS

Seventy one cases of Caesarean and post-partum hysterectomy performed between January 1993 and June 1998.

RESULTS

The rate of peripartum hysterectomy was 1:836 deliveries. Fifty eight per cent of the hysterectomies followed Caesarean section. The main indications for hysterectomy were ruptured uteri, uncontrollable haemorrhage from atonic uteri, sepsis and morbidly adherent placenta. Perinatal mortality was high and there were four maternal deaths.

CONCLUSION

Peripartum hysterectomy is a necessary life-saving operation. Prevention of complications that give rise to emergency hysterectomy should decrease maternal and fetal morbidity and mortality.

Hysterectomy, 1981/82 to 1996/97

OBJECTIVES

This article examines national and provincial trends in hysterectomies from 1981/82 to 1996/97 among women aged 35 or older.

DATA SOURCES

Data for 1981/82 to 1994/95 were obtained from the Hospital Morbidity File maintained by Statistics Canada; for 1995/96 and 1996/97, from the Canadian Institute for Health Information. Supplementary data are from the 1998/99 National Population Health Survey.

ANALYTICAL TECHNIQUES

Descriptive analyses present hospitalization rates for hysterectomy, the percentage performed vaginally, and average length of stay. A hierarchy of indications was used to establish the main reason for hysterectomy. Confidence intervals were calculated to determine significant changes over time and between provinces and the national level.

MAIN RESULTS

From 1981/82 to 1996/97, the hysterectomy rate declined; the proportion performed vaginally increased; and average length of stay for a hysterectomy decreased. These trends generally characterized each province, although there were substantial provincial differences in rates, procedures, and average length of stay.

Biosocial determinants of hysterectomy in New Zealand

OBJECTIVES

This study examined the prevalence and biosocial correlates of hysterectomy.

METHODS

Data were from a 1995 national survey of women aged 20 to 59 years. We applied piecewise nonparametric exponential hazards models to a subsample aged 25 to 59 to estimate the effects of biosocial correlates on hysterectomy likelihood.

RESULTS

Risks of hysterectomy for 1991 through 1995 were lower than those before 1981. University-educated and professional women were less likely to undergo hysterectomy. Higher parity and intrauterine device side effects increased the risk.

CONCLUSIONS

This study confirms international results, especially those on education and occupation, but also points to ethnicity's mediating role. Education and occupation covary independently with hysterectomy. Analysis of time variance and periodicity showed declines in likelihood from 1981.

[Developments in surgical gynecology]

This farewell lecture presents an overview of the development of operative gynecology on the basis of oncological surgery, removal of the uterus with or without pelvic floor reconstruction as well as corrective surgery of the uterovaginal canal. Without doubt the significance of endoscopic surgery, especially involving the adnexa and the cavum uteri, has increased. Uterus extirpation should remain in the domain of the vaginal approach. An experienced 'vaginalist' has has hardly any need for parasocpic assistance which should influence the renaissa lance of the vaginal method. Emphasis should be put on vaginal reconstruction of the affected pelvic floor in the course of incontinence surgery. Thanks to new diagnostic means malformations of the uterus can be detected more frequently, and it appears essential to develop and improve these methods further if one is to prevent laparoscopic polypragmatism. The author's opinion about the insufficient surgical experience and training in medical specialist education will be discussed.

Has endometrial ablation replaced hysterectomy for the treatment of dysfunctional uterine bleeding? National figures

OBJECTIVES

To describe trends in the use of endometrial ablation and hysterectomy for the treatment of dysfunctional uterine bleeding.

DESIGN

Analysis of hospital admissions data.

SETTING

National Health Service Hospitals in England.

POPULATION

Women who underwent a hysterectomy or endometrial ablation for dysfunctional uterine bleeding between 1989 and 1996.

MAIN OUTCOME MEASURES

Annual operation rates and standardised operation ratios for England and for the National Health Service Regions within it, and proportion of operations for dysfunctional uterine bleeding that were endometrial ablations or hysterectomies.

RESULTS

There was an initial rise in operation rates for endometrial ablation until 1992/3, since when the rates have fallen. Hysterectomy rates have remained relatively steady since the introduction of endometrial ablation. The total operation rates for dysfunctional uterine bleeding initially increased but have tended to fall since 1992/3. The ratio of hysterectomy to endometrial ablation for dysfunctional uterine bleeding troughed at 3:1 in 1992/3, but by 1995/6 had increased to 4:1.

CONCLUSIONS

Rather than replacing hysterectomy in the treatment of dysfunctional uterine bleeding, endometrial ablation appears to have added an alternative operative technique. This led to an increase in the total number of operations for this condition, perhaps by lowering the threshold for intervention.

Average charges for three types of hysterectomy procedures: United States, 1998

The average charges associated with three forms of hysterectomies (abdominal-laparotomy) vaginal and laparoscopically-assisted vaginal hysterectomy (LAVH) in 1998 were investigated by geographic area and individual states. Considerable variation in the rates of and charges for these three procedures was reported. Based on data from more than 400,000 women insured under group health contracts, the average charges for these three gynecological surgeries were calculated for the study group of 14,184. The majority of the surgeries were laparotomies (64 percent) with LAVH accounting for only 10 percent; the largest proportion of the procedures were performed in the West South Central and South Atlantic regions of the country and the highest average charge was associated with the LAVH procedures. In 1998, the average charge for an abdominal hysterectomy in the United States was $12,500: that for a vaginal hysterectomy was $10,380; and that for a laparoscopically-assisted vaginal hysterectomy was $14,500. The Pacific area registered the highest average charges for all three (between 19 and 21 percent higher than the U.S. norm) while the lowest geographic area charges were reported in West North Central states (between 18 and 21 percent lower than the U.S. average). The charges in California were the highest of all study states for each of the surgeries, ranging from 38 to 43 percent higher than the average, whereas the charges in Iowa were the lowest for the laparotomies and vaginal hysterectomies (42 and 36 percent, respectively below the norm) and in Kansas for the LAVHs (34 percent lower than the U.S. average). Physicians fees were the highest in New York for each procedure ranging from 33 percent higher than the norm for a vaginal hysterectomy, 50 percent higher for an LAVH and 72 percent higher for a laparotomy. The lowest physician charges were reported in Iowa for the vaginal and abdominal surgeries and in Minnesota for the LAVHs. The average length of stay was 3.10 days for the laparotomy procedures, 2.20 days for the vaginal hysterectomies and 1.99 days for the LAVH patients, with substantial variation between states for each procedure.

[Hysterectomies for benign pathology: is there a place for laparoscopic surgery?]

STUDY OBJECTIVE

To investigate the alternative routes for hysterectomy for benign disease and the appropriate role of laparoscopic surgery.

DESIGN

Retrospective study of hysterectomies performed between August 1991 and July 1997.

SETTING

University hospital.

PATIENTS

Hysterectomy for benign disease without prolapse, pelvic floor relaxation.

INTERVENTION

359 hysterectomies: vaginal (n = 211), laparoscopically-assisted vaginal (n = 56), and abdominal (n = 92).

MEASUREMENTS AND MAIN RESULTS

Uterine volume was the principal indication for laparotomy. Laparoscopy was required only in cases of adnexal disorders or when the vaginal access was limited or associated with extensive adhesions. The rate of laparotomies and laparoscopies dropped steadily over the six-year study period: during the last two years, 75% of all hysterectomies were vaginal, and 90% of those for patients without a previous vaginal birth.

CONCLUSION

With experienced surgeons, the number of cases in which there appears to be poor vaginal accessibility experience decreases, and indications for vaginal hysterectomies increase.

Supracervical hysterectomy: back to the future?

Supracervical hysterectomy, commonly performed in the earlier decades of this century, is rarely performed in contemporary practice. The desire to prevent future cervical cancer initially underlay the advocacy of total hysterectomy. Cervical cytologic screening and effective outpatient treatment of preinvasive cervical disease are commonly available. Cancer of the cervical stump is an uncommon and largely preventable occurrence. Removal of the normal cervix reportedly may have adverse effects on bladder, bowel, and sexual function. Reduced operating time and a shorter recovery period may be associated with a supracervical procedure. The risk of subsequent cervical cancer may not outweigh the benefits of supracervical hysterectomy, which should be offered as an option to selected patients. Supracervical hysterectomy by minilaparotomy is within the capability of practicing gynecologists and may be adaptable to outpatient short-stay surgery, offering a cost-effective alternative for a variety of gynecologic conditions.

Hysterectomy fractions in New South Wales, 1971-2006

Hysterectomy fractions by age group for particular periods are of interest for: estimating proper population denominators for calculation of disease and procedure rates affecting the cervix and uterus; estimating the target population for Pap test programs, and response rates; and as a way of displaying the cumulative consequences of hysterectomies in a population. Hysterectomy fractions for populations can be determined by direct inquiry via a representative sample survey, or, as in this study, from prior hysterectomy rates of the cohorts of women which compose each age bracket. Hysterectomy data 1979-93 were obtained from the hospital In-patients Statistics Collection (ISC) which covers both public and private hospitals in NSW. Annual population denominators of women were obtained from Census data. Data were modelled by Poisson regression, using five-year age group (15- > or = 85 years), annual period, and five-year birth cohort (APC model). Forward- and back-projection of the period effects were undertaken. The resultant NSW hysterectomy fractions by age and period are consistent with fractions obtained from modelled hysterectomy rates for Western Australia (1980-84), and fractions from national representative sample surveys (1989/90 and 1995) for younger women, but not for women aged > or = 70 years in 1995, which revealed higher hysterectomy fractions than modelled hysterectomy data would suggest. Hysterectomy fractions for NSW women by five-year age group for quinquennia centred on 1971 to 2006 are provided.

Emergency hysterectomy in modern obstetric practice. Changing clinical perspective in time

OBJECTIVE

Emergency hysterectomy in obstetric practice is generally performed in the setting of life-threatening hemorrhage. A retrospective review based on hospital data of 67 patients undergoing emergency peripartum hysterectomy over 10 years was undertaken.

METHODS

Comparison of two different time periods regarding the incidence and the indications of obstetric hysterectomies was made.

RESULTS

The number of patients with hysterectomy in the first 5 years of the study period (1985-1989) was 43 and during the last 5 years (1990-1994) it was 24. The incidence of hysterectomy during 1985-1989 was 1 in 2495 deliveries and the most common indication for hysterectomy was uterine atony (42%) followed by placenta accreta (25.5%) and uterine rupture (21%). On the other hand, the incidence of hysterectomy during 1990-1994 was 1 in 4228 deliveries and the ranking of indications of hysterectomy was slightly different from group 1 as mostly placenta accreta (41.7%) followed by uterine atony (29.2%). The maternal mortality rate was 4.5% in this series.

CONCLUSION

This study showed that over the last decade the incidence of emergency hysterectomy in obstetric practice has declined in our clinic due to availability of high standard obstetric care and more liberal use of cesarean section at risk deliveries, better controlled use of oxytocin and internal iliac artery ligation.

Hysterectomy surveillance--United States, 1980-1993

PROBLEM/CONDITION

In the United States, approximately 600,000 hysterectomies are performed each year, and the procedure is the second most frequently performed major surgical procedure among reproductive-aged women.

REPORTING PERIOD COVERED

1980-1993.

DESCRIPTION OF SYSTEM

This surveillance system uses data obtained from CDC's National Hospital Discharge Survey (NHDS) to describe the epidemiology of hysterectomy. The NHDS is an annual probability sample of discharges from non-Federal, short-stay hospitals in the United States.

RESULTS

In the United States during 1980-1993, an estimated 8.6 million women aged > or =15 years had a hysterectomy. The overall rate of hysterectomy declined slightly from 1980 (7.1 hysterectomies per 1,000 women) to 1987 (6.6 per 1,000 women). The redesign of the NHDS in 1988 resulted in a decrease in estimated rates (i.e., the average annual rate for 1988-1993 was 5.5 per 1,000 women). Rates differed by age, with women aged 40-44 years most likely to have this procedure. Overall annual rates of hysterectomy did not differ significantly by race. The diagnosis most often associated with hysterectomy was uterine leiomyoma; during 1988-1993, this diagnosis accounted for 62% of hysterectomies among black women, 29% among white women, and 45% among women of other races. During 1988-1993, the percentage of hysterectomies performed by the vaginal route increased significantly; furthermore, an increasingly higher percentage of vaginal hysterectomies were accompanied by bilateral oophorectomy. From 1991 through 1993, laparoscopy was associated more frequently with vaginal hysterectomy than in previous years.

INTERPRETATION

The rate of hysterectomy decreased slightly during the first half of the 14-year surveillance period, then leveled off during the second half. The increase in simultaneous coding of laparoscopy and vaginal hysterectomy on hospital discharge forms probably reflected the growing use of laparoscopically assisted vaginal hysterectomy.

ACTIONS TAKEN

Continued surveillance for hysterectomy will enable changes in clinical practice (e.g., the use of LAVH) to be identified, and information derived from the surveillance system may assist in directing biomedical assessment priorities (e.g., to determine the reasons for race-specific differences in the prevalence of uterine leiomyoma).

Radical hysterectomy: current management guidelines

Over the past 11 years (January 1985 through December 1996) the senior authors (B.F.H. and H.B.K.) have performed 205 radical hysterectomies. The most notable trend observed was a marked decrease in length of stay from 12.8 days to 3.5 days. Contributing factors include use of the Maylard incision, placement of suprapubic Foley catheters, discontinuation of drains, early oral feeding, admission to the hospital on the day of surgery, and initiation of a critical care pathway. All criteria for short-stay radical hysterectomy were established by 1994. With continued modification of surgical technique and use of the critical care pathway, short stay has become our standard of care for radical hysterectomy. Complications are minimal, with neither long-term morbidity nor mortality associated with the short stay. In addition, significant cost savings occur, which benefits the patient, hospital, and the health care system.

Trends in hospitalizations for abnormal uterine bleeding in the United States: 1980-1992

We examined trends in hospital discharges, length of hospital stay, and procedures performed for abnormal uterine bleeding from 1980 through 1992. We used data from the National Hospital Discharge Survey. Discharges involving patients with reproductive tract cancers or pregnancy-related diagnoses were excluded. The overall discharge rate for abnormal uterine bleeding decreased 66% during the study period, from 56 discharges per 10,000 women in 1980 to 19 per 10,000 in 1992. The discharge rate declined significantly for hospitalizations during which hysterectomy was not performed and remained relatively stable for hospitalizations with hysterectomy. Discharge rates decreased among all age and race groups and in all geographic regions. The percentages of discharges following hysterectomy steadily increased from 25% in 1980 to 72% in 1992. The average length of stay decreased significantly only for discharges for stays during which hysterectomy was performed, from 7.6 days in 1980 to 3.7 days in 1992. During the study period, abnormal uterine bleeding contributed to more than 5 million hospitalizations, 2 million hysterectomies, and 20 million hospital days. Our findings are consistent with a decreased likelihood of hospitalization for abnormal uterine bleeding if hysterectomy was not performed and shorter hospital stays for women undergoing hysterectomy for bleeding. These findings highlight the impact of abnormal uterine bleeding on the U.S. health care system.

Benign ovarian tumors

The aim of this study was to analyze whether, in a series of benign ovarian tumors, the diagnosis could be reliably established and whether the surgical treatment was appropriate. All patients underwent the preoperative evaluation and laparotomy was performed in all cases. The patients were followed for up to 3-8 years after surgery. Demolition surgery (mono or bilateral adnexiectomy with hysterectomy) was more frequently performed in postmenopausal women, while conservative surgery (enucleation, monolateral adnexiectomy) was done in fertile women. Evaluation of the treatment in our series shows that the surgical approach was more aggressive than necessary with respect to the histological diagnosis. Although in the serous and mucinous form tumors on can not rule out the possibility of malignancy in the remaining part of the ovary, the current approach should be more conservative, with enucleation of the mass and preservation of the ovary.