Hysterektomi p

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Hysterektomi på benign indikation

• Daniel Altman
• Enheten för obstetrik och gynekologi
• Institutonen för kliniska vetenskaper KI DS

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Hysterektomi som determinant för
bäckenbottendysfunktion?

• Smyth Ballantyne Br J Surg 1968
• The neuroanatomical basis for denervation of the
  urinary bladder following major pelvic surgery
• Iatrogen skada på n. hypogastricus inferior
  (plexus hypogastricus) och nn. pudendi

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Varför kontrovers?

• Kelly The effect of hysterectomy on ano-rectal
  physiology. Int J Colorect Dis 199813116-8.
• Sood Anorectal dysfunction after surgical
  treatment for cervical cancer. J Am Coll Surg
  2002195513-519.
• Prior Effect of hysterectomy on anorectal and
  urethrovesical physiology. Gut. 199233264-7.
• Shorvon Defecography in normal volunteers
  results and implications. Gut. 1989301737-49.
• Richards A post-hysterectomy syndrome. Lancet
  1974 2 983-5.
• Heaton Bowel function and irritable bowel
  symptoms after hysterectomy and
  cholecystectomy--a population based study. Gut
  1993 34 1108-11.
• van Dam Changes in bowel function after
  hysterectomy. Dis Colon Rectum 1997 40 1342-7.
• Gurnari Chronic constipation after
  gynaecological surgery a retrospective study.
  Ital J Gastroenterol 1988 20 183-6.
• Martinelli. Constipation after hysterectomy
  fact or fiction? Eur J Surg 2000 166 356-60.
• Radley Bowel dysfunction following hysterectomy.
  Br J Obstet Gynaecol 1999 106 1120-5.
• Perry Relationship of gynecologic surgery to
  constipation. J Am Assoc Gynecol Laparosc 1999
  6 75-8.
• Clarke Indications for and outcome of total
  abdominal hysterectomy for benign disease a
  prospective cohort study. Br J Obstet Gynaecol
  1995 102 611-20.
• Weber. Functional outcomes and satisfaction
  after abdominal hysterectomy. Am J Obstet
  Gynecol 1999 181 530-5.
• Goffeng. Does simple hysterectomy alter bowel
  function? Ann Chir Gynaecol 1997 86 298-303.
• Sood Anorectal dysfunction after surgical
  treatment for cervical cancer. J Am Coll Surg
  2002 195 513-9.
• Farquhar A prospective study of the short-term
  outcomes of hysterectomy with and without
  oophorectomy. Aust N Z J Obstet Gynaecol 2002
  42 197-204.
• Prior Effect of hysterectomy on anorectal and
  urethrovesical physiology. Gut 1992 33 264-7.
• Taylor. Effect of hysterectomy on bowel
  function. BMJ 1989 299 300-1.

• Parys. Bladder dysfunction after simple
  hysterectomy urodynamic and neurological
  evaluation. Eur Urol 1990 17 129-33.
• Thakar. Outcomes after total versus subtotal
  abdominal hysterectomy. N Eng J Med 2002 347
  1318-25.
• Virtanen. Effects of abdominal hysterectomy on
  urinary and sexual symptoms. Br J Urol 1993 72
  868-72.
• Griffith-Jones. Adverse urinary symptoms after
  total abdominal hysterectomy--fact or fiction? Br
  J Urol 1991 67 295-7.
• Clarke. Indications for and outcome of total
  abdominal hysterectomy for benign disease a
  prospective cohort study. Br J Obstet Gynaecol
  1995 102 611-20.
• Smith. The neuroanatomical basis for denervation
  of the urinary bladder following major pelvic
  surgery. Br J Surg 1968 55 929-33.
• Peyrat. Prevalence and risk factors of urinary
  incontinence in young and middle-aged women. BJU
  International 2002 89 61-6.
• van der Vaart. The contribution of hysterectomy
  to the occurrence of urge and stress urinary
  incontinence symptoms. BJOG 2002 109 149-54.
• Morgan. Is intrinsic sphincter deficiency a
  complication of simple hysterectomy? J Urol 2000
  164 767-9.
• Diokno. Medical correlates of urinary
  incontinence in the elderly. Urology 1990 36
  129-38.
• Mommsen. Association between urinary incontinence
  in women and a previous history of surgery. Br J
  Urol 1993 72 30-7.
• Brown. Hysterectomy and urinary incontinence a
  systematic review. Lancet 2000 356 535-9.
• Weber. Functional outcomes and satisfaction after
  abdominal hysterectomy. Am J Obstet Gynecol 1999
  181 530-5.
• Prasad. The effect of hysterectomy on urinary
  symptoms and residual bladder volume. J Obstet
  Gynaecol 2002 22 544-7.
• Roovers. Does mode of hysterectomy influence
  micturition and defecation? Acta Obstet Gynecol
  Scand 2001 80 945-51.
• Cosson. Long term complications of vaginal
  hysterectomy a case control study. Eur J Obstet
  Gynecol Reprod Biol 2001 94 239-44.
• Bhattacharya. A comparison of bladder and ovarian
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  endometrial ablation. Brit J Obstet Gynaecol
  1996 103 898-903.

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Metodologiska problem

• Kliniska prospektiva studier små
  studiepopulationer, varierande definitioner av
  sjukdom, och generellt otillräcklig
  uppföljningstid
• Enkätbaserade populationsstudier ofta
  tillräckligt stora men öppna för flera källor av
  selection och recall bias. Tvärsnitts-design.
• RCT svåra att genomföra, små och kort
  uppföljningstid

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Registret över totalbefolkningen
Slutenvårdsregistret
Hysterektomerad cohort n 162,488
Icke-hysterektomerad cohort n 470,519
Cancerregistret
STUDIEPOPULATION
Slutenvårdsregistret
Dödsorsaksregistret
FoB 1990
Immigrationsregistret
Medicinska födelseregistret
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Hysterektomi och inkontinens
Hysterectomy No hysterectomy
Number of subjects included 216,164 644,218
Mean follow-up time (years st.dev.) 11.3 8.0 11.9 7.9
Person-time (years) 2 441,789 7 601,126
Number of persons with SUI surgery 5,642 4,081
Rate per 100,000 person-years (95 CI) 167 (162-172) 74 (72-76)
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Hysterektomi och inkontinens forts.
Risk for SUI surgery hysterectomy vs. no hysterectomy Risk for SUI surgery hysterectomy vs. no hysterectomy
Age at surgery Total
Population quartiles HR (95 CI 
-44 2.5 (2.3-2.6)
45-49 1.9 (1.8-2.1)
50-57 2.2 (2.0-2.4)
58- 2.5 (2.3-2.8)
Overall 2.3 (2.2-2.4)
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Hysterektomi och inkontinens forts.
Risk for SUI surgery hysterectomy vs. no hysterectomy Risk for SUI surgery hysterectomy vs. no hysterectomy Risk for SUI surgery hysterectomy vs. no hysterectomy Risk for SUI surgery hysterectomy vs. no hysterectomy
Time since surgery 0-5 years 5-10 years gt10 years
HR (95 CI) 2.6 (2.4-2.8) 2.3 (2.2-2.5) 1.9 (1.8-2.0)
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Hysterektomi och inkontinens forts.
N Risk for SUI surgery HR (95 CI)
Abdominal total hyst. 147,945 1.0 REF
Abdominal subtotal hyst. 46,517 1.0 (0.9-1.1)
Vaginal hyst. 11,886 1.6 (1.3-1.8)
LAVH 707 1.9 (1.0-3.5)
Laparoscopic hyst. 1,218 1.2 (0.7-2.1)
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Hysterektomi och inkontinens forts.
No hysterectomy No hysterectomy Hysterectomy Hysterectomy
Number of vaginal childbirths HR 95 CI HR 95 CI
0 1.0 Ref 4.2 2.5-6.9
1 2.2 1.4-3.6 5.6 3.2-9.8
2 3.3 2.2-4.9 7.9 5.1-12.3
3 3.6 2.3-5.6 9.9 6.1-16.1
gt4 4.7 2.8-7.7 14.2 7.8-25.6
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Hysterektomi och prolaps
N Risk for POP surgery HR (95 CI)
No hysterectomy 644,218 1.0 REF
Abdominal total hyst. 147,945 1.9 (1.6-2.2)
Abdominal subtotal hyst. 46,517 2.0 (1.9-2.1
Vaginal hyst. 11,886 3.8 (3.1-4.7)
LAVH 707 7.5 (1.5-38.1)
Laparoscopic hyst. 1,218 5.5 (1.6-18.2)
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Sammanfattningsvis

• Hysterektomi är ett säkert och effektivt
  behandlingsalternativ för ett flertal benigna
  gynekologiska sjukdomstillstånd
• Risken för allvarliga perioperativa
  komplikationer är mycket låg
• Långtidseffekter är ännu bristfälligt kartlagda
  men en överrisk för inkontinens, prolaps och
  fistelsjukdom efter hysterektomi måste beaktas