UC Davis researchers who studied hospital discharge records for nearly 650,000 California women over a 13-year period have found that complications from hysterectomies have significantly declined. The study appears in the September issue of Obstetrics & Gynecology, published by the American College of Obstetricians and Gynecologists.
"This is very good news for women who need a hysterectomy," said Lloyd Smith, UC Davis professor of obstetrics and gynecology and lead author of the study. "We found the rates of surgical and medical complications declined significantly for these operations."
The research team also found that the overall number of hysterectomies declined, as well as the rate based on population.
"Hysterectomies are being used more judiciously by California physicians thanks to alternatives for dealing with the pain and excessive bleeding women can experience as they age," Smith explained.
A hysterectomy — the surgical removal of the uterus and sometimes the ovaries and fallopian tubes as well — is the second most common major surgical procedure among reproductive-aged women in the United States. Nearly 600,000 American women undergo the procedure every year and more than one-fourth of U.S. women will have the procedure by the time they are 60 years of age. Hysterectomy can be recommended to correct fibroids, which are muscular tumors that grow in the wall of the uterus, as well as uterine prolapse, bleeding, pain and endometriosis that does not respond to other treatments.
Smith and his colleagues set out to determine how alternative treatments and new surgical techniques have affected women in California. They analyzed data from the California Patient Discharge Database for 649,758 women who underwent hysterectomy procedures between 1991 and 2004 in hospitals for benign, or non-cancerous, conditions. After correcting the data for a variety of demographics and health conditions that may have affected surgical outcomes, the researchers found a 17.6 percent decrease in the total number of hysterectomies.
"In recent years, we've seen a rise in alternatives to treat and manage bleeding," Smith said. "Heavy bleeding is increasingly treated using endometrial ablation to destroy the lining of the uterus by laser, heat or other less invasive methods."
Smith added that surgical methods have also changed. Laparoscopic-assisted vaginal hysterectomy for benign uterine conditions has become more commonplace since first being introduced in 1989. This particular procedure involves a small incision in the abdomen through which much of the surgery to release the uterus is done before it is removed through the vagina. Traditional hysterectomy involves a large abdominal incision. The rate of this type of hysterectomy rose tenfold during the study period, while the complication rate fell significantly.
"Doctors in California have clearly been able to more reliably determine which patients were eligible for laparoscopic-assisted vaginal hysterectomy," Smith said.
Better selection of good candidates for laparoscopic-assisted vaginal hysterectomy and increased surgeon proficiency likely contributed to a 50 percent decrease in surgical and medical complications associated with this type of hysterectomy during the study period.
The researchers also found that the rate of subtotal — or supra-cervical — hysterectomies rose 17-fold during the study period. Smith attributes this to a suggestion in medical literature (unsupported by data from controlled studies) that leaving the cervix in place lowers the impact on sexuality and future urinary problems.
"Women are demanding it because they have seen these reports online and in the popular press. We saw a sharp increase in cases, but we also saw a decrease in complications," Smith said. "The decrease is likely due to the fact that supra-cervical hysterectomies are no longer done only in emergency situations when the cervix proves too difficult to remove."
While the study is unique in scale and the results are significant, Smith pointed out that the data do not include the approximately 1 percent of hysterectomy procedures performed in outpatient surgical centers where patients are not admitted to the hospital. The researchers also relied on coded data each hospital entered that may not have captured all cases or may have been reported in other code categories.
While most of the news was good, there was one very important negative outcome: African-American women had higher rates of medical and surgical complications as well as readmissions to hospitals when compared to non-Hispanic white women. For example, the risk of gastrointestinal tract complication following total abdominal hysterectomy was 50 percent higher in black women when compared to non-Hispanic white women. The findings are consistent with those from other researchers showing that black women undergoing surgery for the removal of fibroids are twice as likely to suffer complications.
"This was an alarming result that we didn't expect to find. We don't understand why the outcomes are so different for black women, but we will study this further to help surgeons nationwide make hysterectomies safer for all women," Smith said.
Smith's UC Davis collaborators on the study were Elaine Waetjen and Clara Paik, associate professors of obstetrics and gynecology, and Guibo Xing, senior statistician with the Center for Healthcare Policy and Research. The study was supported by the UC Davis Department of Obstetrics and Gynecology Research Fund.
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