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Cervical Amputation Versus Vaginal Hysterectomy: a Population-Based Register Study

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Cervical Amputation Versus Vaginal Hysterectomy: a Population-Based Register Study IntUrogynecolJ DOI 10.1007/s00192-016-3119-0 ORIGINAL ARTICLE Cervical amputation versus vaginal hysterectomy: a population-based register study Ida Bergman1 & Marie Westergren Söderberg1 & Anders Kjaeldgaard2 & Marion Ek1 Received: 31 May 2016 /Accepted: 1 August 2016 # The Author(s) 2016. This article is published with open access at Springerlink.com Abstract cervical amputation group, 1.9 % vs 0.2 % (p < 0.001). The Introduction and hypothesis Surgical management of uterine vaginal hysterectomy group also had a longer duration of sur- prolapse varies greatly and recently uterus-preserving tech- gery and greater perioperative blood loss, in addition to longer niques have been gaining popularity. The aim of this study hospitalization. was to compare patient-reported outcomes after cervical am- Conclusions Cervical amputation seems to perform equally putation versus vaginal hysterectomy, with or without con- well in comparison to vaginal hysterectomy in the treatment comitant anterior colporrhaphy, in women suffering from pel- of uterine prolapse, but with less morbidity and a lower rate of vic organ prolapse. severe complications. Method We carried out a population-based longitudinal co- hort study with data from the Swedish National Quality Keywords Anterior colporrhaphy . Cervical amputation . Register for Gynecological Surgery. Between 2006 and Pelvicorganprolapse .Recurrence .Uterineprolapse .Vaginal 2013, a total of 3,174 patients with uterine prolapse were hysterectomy identified, who had undergone primary surgery with either cervical amputation or vaginal hysterectomy, with or without concomitant anterior colporrhaphy. Pre- and postoperative Introduction prolapse-related symptoms and patient satisfaction were assessed, in addition to complications and adverse events. Pelvic organ prolapse (POP) is a common condition amongst Between-group comparisons were performed using univariate the female population and the lifetime risk for prolapse or and multivariate logistic regression. incontinence surgery is 11 % by the age of 80 years, with a Results There were no differences between the two groups in 29 % risk of reoperation [1]. Surgical management of uterine neither symptom relief nor patient satisfaction. In both groups prolapse varies greatly and there are currently insufficient data a total of 81 % of the women reported the absence of vaginal to guide practice [2]. Vaginal hysterectomy, including some bulging 1 year after surgery and a total of 89 % were satisfied kind of vaginal vault suspension, has traditionally been the with the result of the operation. The vaginal hysterectomy most common surgical procedure in the treatment of uterine group had a higher rate of severe complications than the prolapse [1, 3], but uterus-preserving techniques are gaining popularity [4, 5]. Recent studies have shown a desire from the patients to retain the uterus in the case of equal outcome with * Ida Bergman hysterectomy [6, 7]. Uterus-preserving techniques have been [email protected] shown to be associated with less morbidity and shorter hospi- talization [8] and it has also been suggested that hysterectomy 1 Department of Clinical Science and Education, Södersjukhuset, causes damage to the vascular and nerve supply of the pelvis, Karolinska Institutet and the Division of Obstetrics and Gynecology resulting in bladder dysfunction and recurrence of prolapse [9, at Södersjukhuset, Stockholm, Sweden 10]. Procedures such as abdominal sacrocolpopexy and 2 Department of Clinical Sciences, Karolinska Institutet, sacrospinous fixation have been evaluated in randomized tri- Stockholm, Sweden als and have shown high success rates in comparison to Int Urogynecol J vaginal hysterectomy [2, 11, 12]. Randomized trials evaluat- Description of the procedures ing techniques which include amputation of the cervix are lacking. In some papers cervical amputation is even described In the case of concomitant anterior colporrhaphy, this proce- as an obsolete procedure [12]. However, based on the current dure is performed first. Anterior colporrhaphy involves a literature, procedures including amputation of the cervix ap- transvaginal incision of the anterior vaginal wall, 2–3cmpos- pear to be equally as effective with regard to anatomical cure terior to the external urethral meatus almost to the vaginal and recurrence rates, but with less morbidity than vaginal vault or neck of the cervix, and dissection of the bladder from hysterectomy [8, 13–15]. the vagina. The pubocervical fascia is then adapted in the The aim of the present study was to compare the outcomes midline, after which the vaginal epithelium is closed. of cervical amputation versus vaginal hysterectomy, with or In cervical amputation, the cervix is circumcised and the without concomitant anterior vaginal wall repair, in women bladder is dissected from the cervical neck. The peritoneum is suffering from uterine prolapse, using a population-based co- not opened. After amputation of the cervix, the vaginal epi- hort selected from a national quality register. thelium and the cardinal ligaments are often sutured to the stump. In vaginal hysterectomy the vaginal wall around the cervix is circumcised. After bladder dissection, the anterior and pos- terior peritoneum is opened. The uterus is released in several Materials and methods steps using clamps and sutures or an electro-thermal bipolar tissue sealing and dividing system. Vault suspension is often Data source performed by suturing the uterosacral or cardinal ligaments to the vaginal vault. The mucosa is then closed. In this longitudinal cohort study data were collected from the Swedish National Quality Register for Gynecological Outcomes Surgery. The register was established in 1997 and the majority (44 out of 55) of Sweden’s gynecological departments partic- Baseline data were collected both from forms completed by ipate. Collection of data concerning POP surgery started in the physician (age, functional status, and POP-Q) and from the 2006. Data are collected prospectively using patient question- preoperative questionnaire completed by the patient (BMI, naires and forms completed by the physicians. The physicians parity, smoking, cesarean deliveries, use of estrogen replace- report data on admission, surgery, and discharge, including ment therapy, and menopausal status). Functional outcome preoperative gynecological examination of the patient. The measures were retrieved from the questionnaires completed preoperative patient questionnaires include questions by the patients. The primary outcome was patient-reported concerning demographic data and medical history in addition vaginal bulging at the 1 year follow-up questionnaire: BDo to questions about symptoms associated with POP. you experience a feeling of bulging or protrusion in the vag- Postoperative questionnaires are filled in 8 weeks and 1 year inal area?^ The question was dichotomized from five answer after surgery and include questions about POP symptoms, options (never or almost never into Bno^ and 1–3 times per complications, and patient satisfaction. The study design, in- month, 1–3 times per week, and daily into Byes^). Secondary cluding the use of data from the register, was approved by the outcomes included surgical complications and adverse events Regional Board of Ethics in Stockholm, Sweden (Dnr related to the procedure reported by the physician, patient- 2014/958-31/4). reported satisfaction, changes in urinary and bowel symptoms, and sexual function 1 year after surgery. Questions about uri- Study population nary and bowel symptoms were recoded from five answer options into three (never and almost never into Bnever,^ 1–3 The patients included in the study were women with symp- times per month, 1–3 times per week into Bsometimes,^ and tomatic uterine prolapse stage I–IV, with or without anterior daily into B daily^). Sexual activity was reported by answering vaginal wall prolapse stage I–IV, according to the validated the question BHave you had coitus in the past 3 months?^ Data Pelvic Organ Prolapse Quantification System (POP-Q) [16], on complications were reported by the physician at the time of who have undergone either cervical amputation or vaginal surgery and up to 1 year postoperatively. The severe compli- hysterectomy, with or without concomitant anterior cations included severe intra-abdominal bleeding, severe colporrhaphy, between January 2006 and December 2013. intra-abdominal infections or sepsis, ureteric injuries, bowel Exclusion criteria included previous prolapse or urinary in- injuries, myocardial infarction, and severe complications re- continence surgery, a uterus larger than 12 weeks’ gestation, lated to the anesthesia. The mild to moderate complications and concomitant posterior colporrhaphy or enterocele repair. consisted of bladder injuries, lower urinary tract infections or A total of 4,047 patients, meeting the criteria described above, other mild postoperative infections, obstipation, nausea, and were identified in the register database. prolonged postoperative pain, vaginal bleeding, or fatigue. IntUrogynecolJ Statistical analysis Table 3. There were no statistical differences between the two groups neither in symptom relief nor in patient satisfac- Baseline characteristics are presented as means ± SD or me- tion. In both groups a total of 81 % of the women with preop- dians and range for continuous variables and as frequencies erative vaginal bulging were asymptomatic 1 year after sur- for categorical variables. For the comparison
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