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The Loss of Vaginal Hysterectomy

  • Minimally Invasive Gynecologic Surgery (A Yunker, Section Editor)
  • Published:
Current Obstetrics and Gynecology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this review is to provide an update on evidence to support primary use of the minimally invasive approach provided by vaginal hysterectomy in benign conditions that meet criteria for removal of the uterus. This paper will also serve to discuss why the vaginal approach to hysterectomy has decreased over the last decade and to provide observations and solutions to this problem.

Recent Findings

Recent findings continue to support vaginal hysterectomy as the preferred route for hysterectomy as endorsed by position statements by the American College of Obstetrics and Gynecology, the American Association of Gynecologic Laparoscopists, the Society of Gynecologic Surgeons, and in a position statement from the Cochrane Review. Even with this evidence and support from national organizations, the number of endoscopic procedures continues to rise, while vaginal hysterectomy rates drop. Evidence suggests that this may be related to an overall decrease in the number of hysterectomies performed and thus inadequate training and therefore a failure to follow an evidence-based approach to hysterectomy. Changes in training including the increased use of simulation and maximizing exposure to surgical cases for those interested in gynecologic surgical subspecialties by residency tracks are two innovations aimed at improving surgical proficiency.

Summary

As the least invasive and lowest cost route for hysterectomy, vaginal hysterectomy continues to be replaced by endoscopic methods without scientific evidence. As medicine trends toward incentivized payments, this trend will need to change. In order to increase the percentage of vaginal hysterectomies being performed, training and practice patterns need to change to incorporate alternative learning methods and mentorship. Continued research will need to be done to elucidate the impact of these changes on vaginal hysterectomy rate and proficiency.

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Notes

  1. It was recently announced at the 2018 CREOG & APGO annual meeting that the hysterectomy minimums will change for residency graduates on or after June 30, 2019. The abdominal hysterectomy minimum will change from 35 to 15, while vaginal and laparoscopic minimums will be set at 15 each (no change for vaginal and a decrease for laparoscopic, previously set at 20). There will be an increase in the total number of hysterectomies required from 70 to 85 and the minimally invasive hysterectomy category will increase from 35 to 70. This category includes vaginal, laparoscopic, and robotic hysterectomies combined. While the authors appreciate the shift to minimally invasive hysterectomy, they fear that without an increase in the required number of vaginal hysterectomies, the recent changes in required numbers will further push vaginal hysterectomy aside. Programs will use their already strong laparoscopic and robotic surgery numbers to fill the minimally invasive hysterectomy category, leaving residents with the same number of vaginal cases or less than they are currently achieving. This alone will not increase proficiency of vaginal hysterectomy among trainees.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu Y-S, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol. 2013 Aug;122(2, PART 1):233–41.

    Article  PubMed  PubMed Central  Google Scholar 

  2. •• ACOG Committee Opinion No. 444. Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2017;1–5. This reference is of major importance as it provides evidence based guidelines on route of hysterectomy for benign disease as supported by the American College of Obstetrics and Gynecologists.

  3. AAGL Advancing Minimally Invasive Gynecoly Worldwide. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol AAGL. 2011;18(1):1–3.

    Article  Google Scholar 

  4. • Aarts JW, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, et al. Surgical approach to hysterectomy for benign gynaecological disease. In: Kluivers KB, editor, vol. 194. Chichester: Wiley; 1996. This Cochrane database systematic review is of importance as it aims to assess the effectiveness and safety of different surgical approaches to hysterectomy for benign conditions. It includes randomized controlled trials in which clinical outcomes were compared between different surgical approaches to hysterectomy.

  5. Lonnerfors C, Reynisson R, Persson J. A randomized trial comparing vaginal and laparoscopic hysterectomy vs robot-assisted hysterectomy. J Minim Invasive Gynecol Elsevier Ltd. 2015;22(1):78–86.

    Article  PubMed  Google Scholar 

  6. Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomised trial. BMJ. 2004;328(7432):134–0.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Sutton C. The history of hysterectomy. In: Alkatout I, Mettler L, editors. Hysterectomy: a comprehensive surgical approach. Cham: Springer; 2018.

    Google Scholar 

  8. Soranus Gynaecology (Translated). Softshell Books ed. Baltimore: The John’s Hopkins University Press; 1991.

  9. Dicker R, Scally M, Greenspan J, Layde PM, Ory HW, Maze JM, et al. Hysterectomy among women of reproductive age: trends in the United States. JAMA. 1982;248:323–7.

    Article  PubMed  CAS  Google Scholar 

  10. Dicker R, Greenspan J, Strauss L, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol Elsevier Inc. 1982;144(7):841–8.

    Article  CAS  Google Scholar 

  11. Le Tohic A, Dhainaut C, Yazbeck C, et al. Hysterectomy for benign uterine pathology among women without previous vaginal delivery. Obstet Gynecol. 2008:1–9.

  12. Whiteman MK, Hillis SD, Jamieson DJ, Morrow B, Podgornik MN, Brett KM, et al. Inpatient hysterectomy surveillance in the United States, 2000–2004. Am J Obstet Gynecol. 2008;198(1):34.e1–7.

    Article  Google Scholar 

  13. Donnez J, Donnez O, Dolmans M. The current place of medical therapy in uterine fibroid management. Best Pract Res Clin Obstet Gynaecol. Elsevier Ltd. 2018;46:57–65.

    Article  PubMed  Google Scholar 

  14. Cohen SL, Ajao MO, Clark NV, Vitonis AF, Einarsson JI. Outpatient hysterectomy volume in the United States. Obstet Gynecol. 2017;130(1):130–7.

    Article  PubMed  Google Scholar 

  15. Moawad G, Liu E, Song C, Fu AZ. Movement to outpatient hysterectomy for benign indications in the United States, 2008–2014. Dangal G, editor. PLoS One. 2017;12(11):e0188812–5.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Swenson C, Kamdar N, Harris J, et al. Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications. Am J Obstet Gynecol. Elsevier Inc. 2016;215(5):650.e1–8.

    Article  Google Scholar 

  17. Uccella S, Morosi C Marconi N, et al. Laparoscopic versus open hysterectomy for benign disease in uteri weighing >1 kg: a retrospective analysis on 258 patients. J Minim Invasive Gynecol. Elsevier Inc. 2018;25(1):62–9.

    Article  PubMed  Google Scholar 

  18. Morgan D, Kamdar N, Swenson C, Kobernik E, et al. Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women. Am J Obstet Gynecol. Elsevier Inc. 2017:1–35.

  19. Breeden JTM. Statement on robotic surgery by ACOG President James T. Breeden, MD, https://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Statement-on-Robotic-Surgery.

  20. Schmitt JJ, Occhino JA, Weaver AL, McGree ME, Gebhart JB. Outcomes of vaginal hysterectomy with and without perceived contraindications to vaginal surgery. Female Pelvic Med Reconstr Surg. 2017:1–8.

  21. Schmitt JJ, Occino JA, Weaver AL, McGree ME, Gebhart JB. Vaginal versus robotic hysterectomy for commonly cited relative contraindications to vaginal hysterectomy. J Minim Invasive Gynecol Elsevier Inc. 2017;24(7):1158–69.

    Article  Google Scholar 

  22. ACOGCommittee Opinion No. 620. Salpingectomy for ovarian cancer prevention. Obstet Gynecol. 2015;125:279–81.

  23. Rosenblatt KA, Thomas DB. Reduced risk of ovarian cancer in women with a tubal ligation or hysterectomy. The World Health Organization Collaborative Study of Neoplasia and Steroid Contraceptives. Cancer Epidemiol Biomark Prev. 1996;5:933–5.

    CAS  Google Scholar 

  24. Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Gynaecology and Fertility Group, editor. Cochrane Database Syst Rev. 2012;16(2):176–40.

    Google Scholar 

  25. Andersen LL, Zobbe V, Ottesen B, Gluud C, Tabor A, Gimbel H, et al. Five-year follow up of a randomised controlled trial comparing subtotal with total abdominal hysterectomy. BJOG: Int J Obstet Gy. 2014;122(6):851–7.

    Article  Google Scholar 

  26. Mowat A, Maher C, Ballard E. Surgical outcomes for low-volume vs high-volume surgeons in gynecology surgery: a systematic review and meta-analysis. Am J Obstet Gynecol Elsevier Inc. 2016 Jul 1;215(1):21–33.

    Article  Google Scholar 

  27. Walter A. Every woman deserves a high-volume gynecologic surgeon. Am J Obstet Gynecol. Elsevier Inc. 2017;216(2):139.e1–3.

    Article  Google Scholar 

  28. Einarsson J, Matteson K, Schulkin J, Chavan N, Sangi-Haghpeykar H. Minimally invasive hysterectomies—a survey on attitudes and barriers among practicing gynecologists. J Minim Invasive Gynecol Elsevier Ltd. 2010;17(2):167–75.

    Article  Google Scholar 

  29. Moen MD, Richter HE. Vaginal hysterectomy: past, present, and future. Int Urogynecol J. 2014;25(9):1161–5.

    Article  PubMed  Google Scholar 

  30. Schiavone MB, Kuo EC, Naumann RW, Burke WM, Lewin SN, Neugut AI, et al. The commercialization of robotic surgery: unsubstantiated marketing of gynecologic surgery by hospitals. Am J Obstet Gynecol. Elsevier Inc. 2012;207(3):174.e1–7.

    Article  Google Scholar 

  31. Julian TM. Vaginal hysterectomy: an apparent exception to evidence-based decision making. Am J Obstet Gynecol. Elsevier Inc. 2008:1–2.

  32. Janda M, Armfield NR, Page K, Kerr G, Kurz S, Jackson G, et al. Factors influencing women’s decision making in hysterectomy. Patient Educ Couns. Elsevier Ireland Ltd. 2017:1–7.

  33. Review Committee for Obstetrics and Gynecology. Minimum Procedure Numbers: Obstetrics and gynecology. Accreditation Council for Graduate Medical Education. 2017.

  34. Moen M, Walter A, Harmanli O, Cornella J, Mikio N, Rajiv G, et al. Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology. Obstet Gynecol. 2014;124:3585–8.

    Article  Google Scholar 

  35. Woelk JL, Casiano ER, Weaver AL, Gostout BS, Trabuco EC, Gebhart JB. The learning curve of robotic hysterectomy. Obstetrics & Gynecology. 2013;121(1):87–95.

    Article  Google Scholar 

  36. Dune TJ, Blackwell RH, Griffin A, Taege S, Sung J, Mueller ER, et al. Ready or not? Obstetrics and gynecology resident preparedness for female pelvic medicine and reconstructive surgery training. Female Pelvic Med Reconstr Surg. 2017;23(6):401–8.

    Article  PubMed  Google Scholar 

  37. Guntupalli SR, Doo DW, Guy M, Sheeder J, Omurtag K, Kondapalli L, et al. Preparedness of obstetrics and gynecology residents for fellowship training. Obstet Gynecol. 2015;126(3):559–68.

    Article  PubMed  Google Scholar 

  38. Connolly A, Blanchard A, Goepfert A, Donnellan N, Buys E, Uribe R, et al. Surgical skills feedback and myTIPreport. Obstet Gynecol. 2017;130:17S–23S.

    Article  PubMed  Google Scholar 

  39. Cleveland Clinic. Ob/gyn residency: where you design the program. Available at: https://my.clevelandclinic.org/departments/obgyn-womens-health/medical-professionals/education-programs/residency-program. Accessed 17 Feb 2018.

  40. Dave B, Leader-Cramer A, Mueller M, Lewicky-Gaupp C, Kenton K. The wasted vaginal hysterectomy: an argument for tracking in OB/GYN residency programs. Am J Obstet Gynecol. 2016;214:s460.

    Article  Google Scholar 

  41. Hochberg M, Billig J, Berman R, et al. When surgeons decide to become surgeons: new opportunities for surgical education. Am J Surg Elsevier Inc. 2014;207(2):194–200.

    Article  Google Scholar 

  42. Greer JA, Segal S, Salva CR, Arya LA. Development and validation of simulation training for vaginal hysterectomy. J Minim Invasive Gynecol. Elsevier Inc. 2014;21(1):74–82.

    Article  PubMed  Google Scholar 

  43. Kerbage Y, Cosson M, Hubert T, Giraudet G. Multiparous ewe as a model for teaching vaginal hysterectomy techniques. Obstet Gynecol. 2017;130(6):1276–8.

    Article  PubMed  Google Scholar 

  44. Cogbill TH, Shapiro SB. Transition from training to surgical practice. Surg Clin North Am. 2016;96(1):25–33. https://doi.org/10.1016/j.suc.2015.09.001. Review

    Article  PubMed  Google Scholar 

  45. Zakrison TL, Polk TM, Dixon R, Ekeh AP, Gross KR, Davis KA, et al. Paying it forward: four-year analysis of the Eastern Association for the Surgery of Trauma Mentoring Program. J Trauma Acute Care Surg. 2017;83(1):165–9.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Cochran A, Elder WB, Neumayer LA. Characteristics of effective mentorship for academic surgeons: a grounded theory model. Ann Surg. 2017:1.

  47. Kibbe MR, Pellegrini CA, Townsend CM Jr, Helenowski IB, Patti MG. Characterization of mentorship programs in departments of surgery in the United States. JAMA Surg. 2016;151(10):900–6.

    Article  PubMed  Google Scholar 

  48. Okeigwe I, Wang C, Politch JA, Heffner LJ, Kuohung W. Physician-scientists in obstetrics and gynecology: predictors of success in obtaining independent research funding. Am J Obstet Gynecol. 2017;217(1):84.e1–8.

    Article  Google Scholar 

  49. Ichikawa N, Homma S, Yoshida T, Ohno Y, Kawamura H, Kamiizumi Y, et al. Supervision by a technically qualified surgeon affects the proficiency and safety of laparoscopic colectomy performed by novice surgeons. Surg Endosc. 2018;32(1):436–42.

    Article  PubMed  Google Scholar 

  50. Stefanidis D, Anderson-Montoya B, Higgins R, Pimentel M, Rowland P, Scarborough M, et al. Developing a coaching mechanism for practicing surgeons. Surgery Elsevier Inc. 2016;160(3):536–45.

    Article  PubMed  Google Scholar 

  51. DeLancey J, Skinner B. Selecting the route for hysterectomy: a structured approach. Contemporary Ob/Gyn. 2013. http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/content/tags/gynecologic-surgery/selecting-route-hysterectomy-structured-approach.

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Urogynecology and Pelvic Reconstructive Surgery, Vanderbilt University Medical Center, 1161 21st Avenue South, B-1100 Medical Center North, Nashville, TN, 37232, USA

    Joseph Panza & Jessica Heft

  2. Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, Francis and John C. Burch Professor of Obstetrics and Gynecology, Nashville, TN, USA

    Carl Zimmerman

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  1. Joseph Panza
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Correspondence to Joseph Panza.

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Joseph Panza, Jessica Heft, and Carl Zimmerman declare no conflict of interest.

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This article is part of the Topical Collection on Minimally Invasive Gynecologic Surgery

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Panza, J., Heft, J. & Zimmerman, C. The Loss of Vaginal Hysterectomy. Curr Obstet Gynecol Rep 7, 51–57 (2018). https://doi.org/10.1007/s13669-018-0235-5

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