|Year : 2018 | Volume
| Issue : 12 | Page : 48-50
Vaginal hysterectomy at university of Abuja teaching hospital: A 5-year review
Amos Aku Atta, Habiba Ibrahim Abdullahi
Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Abuja, Nigeria
|Date of Web Publication||19-Nov-2018|
Habiba Ibrahim Abdullahi
Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Abuja
Source of Support: None, Conflict of Interest: None
Background: Vaginal hysterectomy is associated with less morbidity and mortality. However, its use appears to be underutilized in most settings in Nigeria. Objectives: The objective of the study was to determine the incidence, indications, and outcome of vaginal hysterectomy at a Nigerian Teaching Hospital. Study Design: A retrospective study of all the hysterectomies performed in the Hospital between January 1, 2010 and December 31, 2014. Results: During the period of study, there were 902 major gynecological operations, of which vaginal hysterectomy accounted for 33, giving an incidence of 3.7%. Vaginal hysterectomy was highest among patients aged 60 years and above accounting for 54.6%. The most common indication for vaginal hysterectomy was uterovaginal prolapse constituting 75.8%. The complication rate was 27.3% with postoperative pyrexia constituting 57.1% of all the complications, while hemorrhage was the least, constituting 3.0%. There was no mortality recorded. Conclusion: The incidence of vaginal hysterectomy was 3.7%. Uterovaginal prolapse was the most common indication, while postoperative pyrexia was the most common complication found.
Keywords: Incidence, indication, outcome, University of Abuja Teaching Hospital, vaginal hysterectomy
|How to cite this article:|
Atta AA, Abdullahi HI. Vaginal hysterectomy at university of Abuja teaching hospital: A 5-year review. N Niger J Clin Res 2018;7:48-50
| Introduction|| |
Hysterectomy is a surgical procedure which involves the removal of the uterus and this could be done through the abdominal, vaginal, or laparoscopic route.,, The choice of route of hysterectomy depends on the patients' clinical condition and the technical expertise of the surgeon.,, Vaginal hysterectomy which is the removal of the uterus and cervix through the vagina is associated with lower overall morbidity and mortality, reduced operative time, shorter hospital stay, and reduced cost to the patient in benign gynecological conditions., It is also the preferred route for obese women., However, abdominal hysterectomy is the favored route of hysterectomy worldwide in spite of the advantages of vaginal route. The ease and convenience by which hysterectomy can be performed through a wider abdominal incision and the paucity of surgical expertise required for vaginal hysterectomy have made abdominal hysterectomy a preferred route for majority of gynecologists., Laparoscopically assisted vaginal hysterectomy is associated with less postoperative morbidity, shorter hospital stay, and quicker return to normal activity. When vaginal hysterectomy is not an option, laparoscopically assisted vaginal hysterectomy is the best alternative. It also has added advantage of inspection of the peritoneal cavity and ovaries., However, it has not gained popularity in Nigeria because of lack of expertise, unavailability of the equipment, and the high cost.
Vaginal hysterectomy is scantly performed in Nigeria when compared to the incidence in the developed countries. Hence, there is little exposure and transfer of the skills to the resident doctors. Periodic auditing of this less frequently employed surgical intervention is imperative; hence, the need for this study to awaken us to increase our utilization of this technique when indicated. It is estimated that 84% of all hysterectomies could be performed vaginally. The famous French surgeon; Doyen in 1939 said that “no one could call himself a gynaecologist until he performed vaginal hysterectomy.” The study seeks to determine the incidence, indication, and outcome of vaginal hysterectomy in University of Abuja Teaching Hospital (UATH).
| Materials and Methods|| |
This was a retrospective study of vaginal hysterectomies conducted at UATH, in Nigeria's Federal Capital Territory between January 1, 2010 and December 31, 2014. The patient's identification numbers were retrieved from the gynecological ward admission registers and from the theater operation registers. Their case notes were retrieved from the medical record department and analyzed for sociodemographic characteristic, indications for surgery, cadre of surgeon, duration of hospital stay, and postoperative morbidity and mortality. A postoperative temperature of 38°C or more on two consecutive occasions 4 h apart, after the 1st postoperative day was considered as pyrexia. The data were analyzed using Microsoft Excel spreadsheet.
| Results|| |
During the period of study, there were 902 major gynecological operations, of which 155 were abdominal hysterectomies and 33 were vaginal hysterectomies. The 33 folders were retrieved from the medical records and analyzed.
A total of 188 hysterectomies were performed during the study period. Vaginal hysterectomy constituted 3.7%, while abdominal hysterectomy constituted 17.2% of all major gynecological operations. Of the 188 hysterectomies performed during the period, 155 (82.4%) were abdominal hysterectomies and 33 (17.6%) were vaginal hysterectomies. The ratio of cases of abdominal hysterectomy to vaginal hysterectomy was approximately 5:1.
The sociodemographic characteristics of the patients are as shown in [Table 1]. The vaginal approach for hysterectomy was highest among patients who were 60 years or more (11, 33.3%). Majority of the patients (22, 66.6%) were grand multiparas.
The most common indication for vaginal hysterectomy was uterovaginal prolapse and was seen in 25 (75.8%) of the cases as shown in [Table 2]. Majority (19, 57.6%) of the patients had spinal anesthesia, while 14 (42.4%) had general anesthesia. Local anesthesia was not used for any of the cases.
In 31 (96%) of the patients, the vaginal hysterectomy was carried out by consultants as shown in [Table 3]. During the period under review, the most common complication was postoperative pyrexia, constituting 12.1% of all complications, while hemorrhage was the least, constituting 3.0%, as shown in [Table 4]. Most of the patients (19, 57.6%) were discharged earlier than 5th postoperative day.
| Discussion|| |
The ratio of abdominal to vaginal hysterectomy in this study was 5:1. The ratio of abdominal to vaginal hysterectomy generally varies from 2:1 to 9:1 depending on the geographical region., It is estimated that about 84% of all hysterectomies could be performed vaginally. Perhaps, working toward having clear guidelines for selecting a surgical route may improve the utilization of vaginal hysterectomy.
The incidence of vaginal hysterectomy from this study is similar to that of Nnewi (3.7%), Ile-Ife (3.3%), and Jos (3%),,, but higher than 2.2% reported from Gombe, 1.1% from Kano, and 1% from Lagos.,, It is much lower than the figure quoted from the United States (8%). This disparity probably reflects the absence of clear guidelines for selecting a surgical route, surgeon's skill, experience, and preference. Uterine myomas in our environment which are often of huge sizes coupled with the high incidence of pelvic adhesions may make vaginal approach difficult.
Vaginal hysterectomy was the most common among the age group 60 years and above. This is similar to other studies.,,, Vaginal hysterectomy was 66.6% among grand multipara. This is expected as this group of women are at higher risk of development of uterovaginal prolapse which has been found to be the most common indication for vaginal hysterectomy in our study as well as previous studies.,,, Estrogen deficiency and damage to the pelvic support structures from repeated vaginal deliveries easily predisposes them to uterovaginal prolapse.
Vaginal hysterectomy was performed by the consultant gynecologist in 96% of the patients and only 2 cases (4%) were carried out by the resident doctors. In a study in Jos, 87% of the vaginal hysterectomies were carried out by the consultants, while 13% were carried out by the residents. In Nnewi, all the vaginal hysterectomies were carried out by the consultants. These findings show that there is underexposure of residents in training in the art of vaginal hysterectomy in Nigeria.
The relative absence of complications apart from postoperative pyrexia which may have been contributed by other causes of pyrexia such as malaria affirms to the safety of vaginal hysterectomy. In addition, the benefit of early discharge was evident from this study and corroborated by previous studies comparing vaginal hysterectomy and abdominal hysterectomy.,
| Conclusion|| |
The incidence of vaginal hysterectomy from the study is low with uterovaginal prolapse being the commonest indication. There is need to increase utilization of this surgical procedure and transfer of the skills to doctors in training.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Papadopoulos MS, Tolikas AC, Miliaras DE. Hysterectomy-current methods and alternatives for benign indications. Obstet Gynecol Int 2010;2010. pii: 356740.
Wieslander CK, Wong KS. Therapeutic gynecologic procedures. In: Decherney AH, Nathan L, Laufer N, Roma AS, editors. Current Diagnosis & Treatment Obstetrics & Gynaecology. 11th
ed. Accra: McGraw Hill Medical Publication; 2013. p. 783-92.
Tindall VR. Tumor of the cervix uteri. In: Jeffcoate's Principles of Gynaecology. 5th
Edition. London: Butterworth; 1986. p. 395-416.
Shiota M, Kotani Y, Umemoto M, Tobiume T, Shimaoka M, Hoshiai H, et al.
Total abdominal hysterectomy versus laparoscopically-assisted vaginal hysterectomy versus total vaginal hysterectomy. Asian J Endosc Surg 2011;4:161-5.
Jahan S, Das TR, Mahmud N, Mondol SK, Habib SH, Saha S, et al.
Acomparative study among laparoscopically assisted vaginal hysterectomy, vaginal hysterectomy and abdominal hysterectomy: Experience in a tertiary care hospital in Bangladesh. J Obstet Gynaecol 2011;31:254-7.
Pratt JH, Daikoku NH. Obesity and vaginal hysterectomy. J Reprod Med 1990;35:945-9.
Sheth SS. Vaginal hysterectomy as a primary route for morbidly obese women. Acta Obstet Gynecol Scand 2010;89:971-4.
Kovac SR. Clinical opinion: Guidelines for hysterectomy. Am J Obstet Gynecol 2004;191:635-40.
Brill AI. Hysterectomy in the 21st
century: Different approaches, different challenges. Clin Obstet Gynecol 2006;49:722-35.
Harris MB, Olive DL. Changing hysterectomy patterns after introduction of laparoscopically assisted vaginal hysterectomy. Am J Obstet Gynecol 1994;171:340-3.
Ocheke AN, Ekwempu CC, Musa J. Underutilization of vaginal hysterectomy and its impact on residency training. West Afr J Med 2009;28:323-6.
Kovac SR. Transvaginal hysterectomy: Rational and surgical approach. Eur J Obstet Gynecol Reprod Biol 2005;120:232-3.
Green-Armytage VB. Vaginal hysterectomy: New technique-follow-up of 500 consecutive operations for haemorrhage. J Obstet Gynaecol Br Empire 1939;46:848-56.
Obiechina NJ, Ugboaja JO, Onyegbule OA, Eleje GU. Vaginal hysterectomy in a Nigerian tertiary health facility. Niger J Med 2010;19:324-5.
Owolabi AT, Adegoke AS, Fasubaa OB, Ogunnuyi SO. Vaginal hysterectomy – A 10 year review at Obafemi Awolowo University Teaching Hospital, lle-lfe. Niger J Health Sci 2010;7:78-83.
Daru PH, Pam C, Shambe I, Magaji A, Nyango D, Karshima J. Vaginal hysterectomy at Jos University Teaching Hospital. Trop J Obstet Gynecol 2012;6:65-71.
Bukar M, Audu BM, Yahaya UR. Hysterectomy for benign gynecological conditions at Gombe, North Eastern Nigeria. Niger Med J 2010;51:35-8. [Full text]
Ahmed ZD, Taiwo N. Indications & outcome of gynecological hysterectomy at Aminu Kano Teaching Hospital, Kano: A 5-year review. Open J Obstet Gynecol 2015;5:298-304.
Awoleke JO. An audit of hysterectomy at the Lagos University Teaching Hospital, Lagos. Trop J Obstet Gynaecol 2012;29:96-102.
Farguhar CM, Steiner CA. Hysterectomy rates in the United States 1900-1997. Obstet Gynecol 2002;99:229-34.
Obed SA. Pelvic relaxation. In: Kwawukume EY, Emuveyan EE, editors, Comprehensive Gynaecology in the Tropics. Graphic Packaging Limited Accra 2005; p
Okeke TC, Ikeako LC, Ezenyeaku CC. Under exposure of residents in training in the art of vaginal hysterectomy in Nigeria. Am J Clin Med Res 2014;2:22-5.
[Table 1], [Table 2], [Table 3], [Table 4]