Hysterectomy in a Southwestern Tertiary Unit in Nigeria: A 5-Year Review

Abstract

Background: Hysterectomy is one of the commonest major gynecologic surgeries performed worldwide. While the procedure is highly successful for curing diseases, especially nonmalignant conditions, it is not without risks. Objective: The aim of this research was to review hysterectomies in Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria, with respect to indications, types, outcomes, and complications over a 5-year period. Materials and Methods: This was a descriptive retrospective study conducted from January 1, 2005 to December 31, 2009. Case records of patients who underwent hysterectomy were retrieved to obtain information on sociodemographics, types of hysterectomy, elective or emergency surgeries, blood losses, blood units transfused, and surgical complications. Results: Of 1859 major gynecologic surgeries during the study period, there were 196 hysterectomies, an incidence of 10.5%. Mean ages of the patients were 46.83 ± 9.18 years (elective surgery) and 40.28 ± 6.82 years (emergency surgery). Mean parity was 3.67 ± 2.06 for elective surgery and 3.86 ± 0.9 for emergency surgery. Uterine fibroid was the commonest indication at 61.44%, followed by ovarian mass at 7.84%. Mean blood loss was higher (3510 ± 1384) mL in emergency surgery, compared to (886.6 ± 587) mL in elective surgery (p = 0.023). Thus, the mean unit of blood transfusion was 6.57 ± 2.23 units in emergency surgery versus 1.82 ± 2.0 units in elective surgery (p = 0.031). Complications included hemorrhage at 8.3%, urinary tract infection at 3.5%, wound infection at 2.1% and intestinal obstruction at 0.7%. Three death (1.8%) were all attributed to severe hemorrhage. Conclusions: To achieve the most favorable outcome, appropriateness of the surgery must be evaluated carefully along with available options in the context of the patient's disease process. (J GYNECOL SURG 32:335)

Introduction

Hysterectomy is one of the commonest major gynecological surgeries performed all over the world.¹ Hysterectomies are commonly performed in many tertiary health institutions in Nigeria. This surgery accounts for 28% of all major gynecologic operations at the University College Hospital, in Ibadan, Nigeria, coming after salpingectomy for ectopic pregnancy.² Hysterectomy has a wide range of indications, including treatment for uterine and ovarian cancer and various noncancerous uterine conditions that lead to disabling levels of pain, discomfort, uterine bleeding, and emotional stress.³

Uterine fibroid is the commonest indication for hysterectomy, especially in women who are no longer of reproductive age.⁴ Although the procedure is highly successful for curing diseases, especially nonmalignant conditions, it is not without risks.⁵ It is a surgical option with accompanying risks of morbidity and mortality that a major operative procedure would carry and induces sterility in premenopausal women.³ Complications, such as excessive bleeding, wound infection, and injury to adjacent organs, can also occur as well as urinary-tract infection (UTI) from catheterization.⁶

All large-scale surveys of hysterectomies show that 70%–80% of hysterectomies are performed by the abdominal approach except uterovaginal prolapse, for which the vaginal route is normally used. This accounts for about 10% of all hysterectomies performed.^3,4 Randomized studies comparing different routes suggest that vaginal or laparoscopic hysterectomy is associated with a shorter hospital stay and faster recovery than laparotomic hysterectomy.⁷ The route of hysterectomy is based on clinical and technical factors, such as the primary indication for the operation, uterine weight, previous pelvic surgery, previous vaginal deliveries, or the need for morcellation or concomitant adnexectomy.⁸

As a result of the varying nature of data generated with respect to indication, incidence, type of hysterectomy, and outcome, a review of hysterectomies performed in Ayinke House of the Department of Obstetrics and Gynecology, Lagos State University Teaching Hospital, in Ikeja, Lagos, Nigeria, facility was conducted. The aim was to review hysterectomy procedures, with respect to indications, types, outcomes, and complications, over a 5-year period.

Materials and Methods

This was a descriptive retrospective study conducted from January 1, 2005, to December 31, 2009. It was approved by the institution's ethics and research committee. Case records of patients who had hysterectomies performed at Lagos State University Teaching Hospital were retrieved from the medical records section for data collection. Information was obtained on age, parity, occupation, type of hysterectomy performed, and complications. Other data extracted included elective or emergency nature of the surgery, blood loss, unit(s) of blood transfused, and outcome for each patient. Surgeries were performed mostly by consultants who were assisted by senior registrars and, occasionally, by proficient senior registrars assisted by the junior residents. The preoperative scrubbing procedure used chlorexidine solution, followed by methylated spirits for abdominal approach and chlorhexidine only for the vaginal route.

Data were represented by simple proportion and frequency tables. Analysis was conducted to obtain means and standard deviations (SDs), using Microsoft Office Excel's 2010 version. The confidence level was set at 95% and a p-value <0.05 was considered to be statistically significant.

Results

Of the 196 hysterectomies performed during the study period, case records of 153 patients were retrieved for analysis. The total number of major gynecologic surgeries performed during the study period was 1859, an incidence of 10.5%. Table 1 shows the patients' age range from 11 to 79 years, with a mean of 46.83 ± SD 9.18 years. Patients who had emergency hysterectomies had a mean age of 40.28 ± SD 6.82 years; hence, there was no statistically significant difference between the age groups (p = 0.72). Most of the subjects were multiparous, with 68.6% having 3 or more children. The mean parity was 3.67 ± 2.1 for all patients, whereas patients who had emergency hysterectomies had a mean parity of 3.86 ± 0.90 (Table 2). This difference was not statistically significant (p = 0.92; Table 3).

Table 1.

Age Distribution in Years

Age	Frequency
11–20	1 (0.6%)
21–30	1 (0.6%)
31–40	30 (19.7%)
41–50	84 (54.9%)
51–60	26 (17.0%)
61–70	8 (5.2%)
71–80	3 (2.0%)
Total	153 (100%)

Mean age ± standard deviation = 46.83 ± 9.18 years.

Table 2.

Parity Distribution

Parity	Frequency
0	8 (5.2%)
1–2	40 (26.2%)
3–4	54 (35.3%)
≥ 5	51 (33.3%)
Total	153 (100%)

Table 3.

Differences Between Elective and Emergency Surgery

Variable	Elective Mean SD	Emergency Mean SD	p-Value
Age (years)	46.83 9.179	40.28 6.82	0.72
Parity	3.67 2.06	3.86 0.90	0.94
Blood loss (mL)	886.6 587.34	3500 1384	0.023
Transfusion (units)	1.82 2.00	6.57 2.23	0.031

SD, standard deviation.

Table 4 shows the indications for, and frequency of, hysterectomies. Uterine fibroids were responsible for 61.44% of the hysterectomies in this study, followed by ovarian masses accounting for 7.84% of these. Surgical approach to hysterectomy is shown in Table 5, with abdominal approach accounting for 93.4% of procedures performed and vaginal hysterectomy performed in 10 (6.6%) patients. The complication rates and routes of surgical approach are presented in Table 6. As shown in this table, 18.8% of patients who had an abdominal approach had complications, with excessive bleeding accounting for 8.3% and UTIs occurring in 3.5% of these patients. However, only 1 (10%) of those who had vaginal hysterectomies had a UTI. Two cases of postoperative pyrexia were recorded in the abdominal approach group, compared to none in patients who had vaginal hysterectomies.

Table 4.

Indications for Hysterectomy

Indications	Frequency
Fibroids	94 (62.4%)
Ovarian mass	12 (7.8%)
Ureto-vaginal prolapse	9 (5.8%)
Adenomyosis	7 (4.5%)
Cervical dysplasia	7 (4.5%)
Ruptured uterus	6 (3.9%)
Postmenopausal bleeding	5 (3.2%)
Endometrial cancer	5 (3.2%)
Dysfunctional uterine bleeding	3 (1.9%)
Endometrial hyperplasia	3 (1.9%)
Endometrial polyp	2 (1.3%)
Total	153 (100%)

Table 5.

Surgical Approach to Hysterectomy

Type	Frequency
TAH	30
TAH + USO	19
TAH + BSO	80
STAH	8
STAH + USO	3
STAH + BSO	3
VAH	6
VAH + colporrhaphy	4
Total	153

TAH, total abdominal hysterectomy; USO, unilateral salpingo-oophorectomy; BSO, bilateral salpingo-oophorectomy; STAH, subtotal abdominal hysterectomy; VAH, vaginal hysterectomy.

Table 6.

Complications and Surgical Approaches to Hysterectomy

Complications	TAH	STAH	VAH
Bleeding	12	1	–
Urinary-tract infection	5	1	1
Wound infection	3	1	–
Fever	2	–	–
Intestinal obstruction	1	–	–
Vesico-vaginal fistula		1	–
Total	27 (18.8%)		1 (10%)

TAH, total abdominal hysterectomy; STAH, subtotal abdominal hysterectomy; VAH, vaginal hysterectomy.

Some parameters showed significant difference between elective and emergency surgery as shown in Table 3. The mean blood loss for elective surgery was 886.6 ± 587.34 mL while that of emergency surgery was 3510 ± 1384 mL (p = 0.023). The mean unit(s) of blood transfused for elective surgery was 1.82 ± 2.00, while that of emergency surgery was 6.57 ± 2.23 (p = 0.031). The mean duration of hospital stay in all patients was 13.97 ± 8.13 days.

Discussion

The findings in this study showed that hysterectomy constitutes 10.5% of all gynecologic procedures, which is higher, compared to other studies.^9–11 However, abdominal approach to surgery comprised 93.4% of all of these procedures, which was in contrast to 75% occurring in Europe and America.¹² Laparoscopic approach to this procedure is uncommon in the current authors' environment for various reasons, among which are limited surgical skills and expertise, nonavailability of the required equipment, and the huge size of uterine masses presented.

The wide age range of the study group reflected all possible indications for hysterectomy. The patient who was age 11 had total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy for a suspected ovarian malignancy, which was confirmed to be a poorly differentiated endodermal sinus tumor; she died of advanced metastasis 2 months later. The majority of the patients (75%) were in the reproductive-age group; this possibly could be an explanation for why uterine fibroids, at 61.4%, was the commonest indication for hysterectomy in the study population.

Considering the parity, the majority of the patients were multiparous with only 8 (5.2%) being nulliparous. About half of the subjects were traders, with civil servants and teachers comprising 18% and 13%, respectively; however, the role of occupation in relation to indication for hysterectomy has yet to be defined. The occurrence of uterine fibroids and the complication of a pressure effect with menorrhagia has been established worldwide as the commonest indication for hysterectomy. Hysterectomy is usually a better option than myomectomy, when the age and parity of the patient make further pregnancy unlikely or undesirable.¹¹ Furthermore when hysterectomy is performed, fibroids cannot recur and the symptoms can be relieved with certainty. In addition, hysterectomy is easier to perform, there is less blood loss, and less postoperative morbidity.¹³

It is noteworthy that the indications for hysterectomy in completely asymptomatic patients are few and include rapidly enlarging fibroids or enlarging fibroids after menopause, as seen in some of the patients when concerns regarding leiomyosarcoma are raised.¹⁴

The choice of surgical approach depends on surgeon expertise, the indication for surgery, the nature of the disease, and the patient's characteristics. Choices and options are as outlined earlier.^3,12 In this study, the abdominal approach was used in 93.4% cases, with a complication rate of 18.8%, 8.3% of which were the result of excessive hemorrhage. The vaginal approach was used sparingly (6.6%) in during this study period, most likely, because very few indications existed for it. Uterovaginal prolapse managed by vaginal hysterectomy occurred in 5.8% of the patients. Several studies have shown that the vaginal approach has lower morbidity and shorter recovery time than abdominal hysterectomy; hence, the vaginal approach should be offered if feasible.¹⁵ The benefits and risks of each approach should be examined critically according to patients' needs, because there is not any evidence that subtotal hysterectomy reduces the risk of pelvic-floor prolapse nor is there any evidence that total hysterectomy affects sexual function.^16,17

An interesting difference found between elective and emergency surgery, as shown in Table 3, indicates that emergency cases, which were mainly peripartum hysterectomies had large amounts of blood loss and received more blood transfusions than their elective counterparts. This finding was similar to that of Ezechi et al.,¹⁸ because the cases involved had uterine rupture with massive intraperitoneal bleeding. The researchers reported a mean operative blood loss of 4865 mL, compared to the 3500 mL in the current study. The researchers' mean transfusion was 9.73 units ± SD 4.19, while the mean transfusion in the current study was 6.57 units (SD = 2.23).

It was also noted that 23 patients who received elective surgery had complications, compared to 2 patients who had emergency surgery. The 2 emergency cases had postoperative hemorrhage and vesico-vaginal fistulae related to ruptured uteri. Three deaths were recorded, giving a case fatality rate of 1.8%, which is very high, compared to 0.5–2/1000 reported for developed countries.¹¹ These deaths were all associated with severe hemorrhage. No case of visceral damage was attributed to the procedure in both the elective and emergency groups.

The occurrence of complications according to surgical approach revealed that TAH was associated with more cases of hemorrhage (12 subjects) and UTI (5 subjects), compared to only 1 in those that had subtotal abdominal hysterectomy (STAH). Wound infection is also three times more common in the former approach than the latter one. This is not surprising, because STAH is a safer operation, whatever the skill of the surgeon might be. Hematoma and wound infection is less likely to occur with STAH, whereas, with TAH, there is contamination of the abdominal cavity by vaginal flora during the procedure.¹¹ The occurrence of pyrexia complicating abdominal hysterectomies in the current study was almost 1.4%, in only 2 patients, while no occurrences of pyrexia were observed among patients who had vaginal hysterectomy. This contrasts with findings in other reports.^1,13 Only 1 patient among the 10 who had vaginal hysterectomies had a UTI.

All patients who were operated on had antibiotic therapy with intravenous 500 mg of ampicillin/cloxacillin every 6 hours and 500 mg of metronidazole every 8 hours, although regimens can vary. While elective cases had prophylactic antibiotics for 24 hours, other patients with indications such as ruptured uteri, ovarian masses, and endometrial cancers had antibiotics therapy for 7 days, with changes from parenteral to oral administration after commencement of oral intake. Patients with fever or wound sepsis had wound swabs taken and their antibiotics changed according to sensitivity patterns.

However, cyclical vaginal bleeding and development of carcinoma of the cervix from the cervical stump are the drawbacks of subtotal hysterectomy. The mean duration of hospital stay in this study was 13.97 ± 8.19, which was longer than the 9.9 ± 2.7 days reported by Ezechi et al.¹⁸ The period given was total duration of hospital stay from admission to discharge. Some cases, such as uterine fibroid with menorrhagia, were admitted for blood transfusion to correct for anemia prior to surgery. The other factor prolonging the duration of hospital stay was delay in payment of a medical bill.

Conclusions

This study had limitations in being a retrospective study and in its inability to retrieve all case files. Information that could help in analyzing the indications for hysterectomy and development of sexual or bladder dysfunction could not be obtained, as this is only possible at follow-up.

Important outcomes for patients included relief of symptoms, minimal complications, and optimum quality of life (QoL). In order to achieve the most favorable outcome, the appropriateness of the surgery must be evaluated carefully along with available options in the context of each patient's disease process. Hysterectomy is highly effective for relief of symptoms and improvement of QoL.¹⁵

Footnotes

Author Disclosure Statement

No financial conflicts exist.

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