Introduction
Hysterectomy is said to have been done when the uterus
with or without the adnexal structures are surgical removed.
This could be done through the laparoscopic, vaginal or abdominal route [1,2]. It is a common gynecological surgery performed on women in the peri and postmenopausal period [3].
Many factors may influence the choice of approach. This include the surgeon’s skill, the reason for the surgery, as well as
other clinical conditions [4]. Abdominal and vaginal hysterectomies are commonly utilized in low and middle-income countries
due to reduced skills and facility for laparoscopic approach. Abdominal hysterectomy entails harvesting the uterus through
an abdominal incision. Vaginal hysterectomy entails harvesting
the uterus via the vagina and thereafter aborting the space the
uterus originally occupied with tissues derived from its lateral
attachments [5]. Hysterectomy via laparoscopic route leads to
increased operating time and decreased intra- and postoperative complications [6]. Abdominal hysterectomy has the disadvantage of larger incisions, handling of the abdominal organs
and an extended time of recovery. Less invasive techniques like
vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy are increasingly popular among gynaecologists [7].
In comparing with abdominal hysterectomy, vaginal hysterectomy has shorter operating time, shorter duration of stay in
the hospital, more rapid recuperation, reduced complications,
reduced cost to the patient, lower overall complications while
laparoscopically assisted vaginal hysterectomy leads to less pain
postoperatively and shorter duration of stay in the hospital [7].
The rate of hysterectomy varies worldwide according to geographic distribution [8]. Annually about 600000 hysterectomies
are done in the USA, 64% of these were via abdominal route
while in UK 1 in 5 women by age 60 would have had a hysterectomy [8,9]. Most studies on practice of hysterectomy showed
that 70-80% of them are done through the abdominal route [2].
Vaginal and laparoscopic hysterectomies are associated with
less complications. However, the incurred charge, skill, and non
availability of equipment make abdominal hysterectomy procedure of choice in low and middle-income countries [10]. The
prevalence rate of 9.4% for hysterectomies was reported in Lagos state in Nigeria [11].
In our environment, the most common indication for abdominal hysterectomy is uterine fibroids while for vaginal hysterectomy; the most common indication is uterovaginal prolapse [8].
Other indications for hysterectomy may include adenomyosis,
premalignant lesion of uterus and cervix after completion of
family size, chronic pelvic pain, abnormal uterine bleeding, cancer of the endometrium, cervical polyp and cancer of the cervix
[8]. After hysterectomy, most of women are relieved of their
symptoms and this gives them a high level of satisfaction with the procedure [3].
The complications that may follow hysterectomy include
injury to the surrounding structures, postoperative pyrexia, infections, hematoma in the pelvis among others [4]. Hysterectomy is affected by a lot of beliefs (cultural, psychosocial and
religious), especially in our environment where women often
have aversion for surgery, loss of femininity or refusal of sex by
their partners [3,13].
To the best of the knowledge of the researcher, comparisons
of different gynecological hysterectomies have not been studied in our institution, hence the need for this work. The aim of
the study is to determine the prevalence, biosocial characteristics and to compare the outcomes of the gynecological hysterectomies done at NAUTH, Nnewi, Nigeria as this will help in
proper selection of type of hysterectomy and thus improve the
outcome.
Methods
Study design: A retrospective cross-sectional comparative
study.
Study population: The study was conducted among women
that had gynecological hysterectomies.
Study site:
Gynecological theater and gynecological ward of Nnamdi
Azikiwe University Teaching Hospital, Nnewi, Nigeria. This hospital has many consultant obstetrician-gynecologists, trainee
doctors (registrars and senior registrars) and ancillary medical
staff. It is a training center for medical post-graduate studies in
Nigeria. It is a government-funded referral center for maternal
and newborn care. It provide comprehensive emergency and
elective gynecological care, and serves as major referral center
for gynecological services in south-eastern Nigeria.
Eligibility Criteria
Inclusion criteria:
This included women that underwent gynecological hysterectomies during the study period (from 1st January, 2013 to
31st December, 2018).
Exclusion criteria:
Women who had myomectomy were excluded from the
study. The cases of missing or incomplete data were also excluded from the study.
Sample size determination
The sample size was an all population based study.
Sample technique: Non-random sampling approach. All
available case files were examined.
Study Outcome Measures
Hysterectomy rates, types of hysterectomy, duration of stay
in the hospital, complications and mortalities.
Procedures Involved
The main theatre, gynecology ward and gynecology theatre
records were reviewed to identify women that underwent gynecological hysterectomy during the study period. The patients’
case records were then retrieved from the hospitals’ medical
record department. For the gynecological variables, data were
extracted from the gynecological Registers and medical records
by trained data collectors using a data retrieval form. The patients’ socio-demographic characteristics include age, parity
and other information like hysterectomy type, duration of stay
in the hospital, complications and mortalities were retrieved
from the patients’ case notes and analyzed. Completed forms
were then assessed by a data coordinator for completeness and
accuracy before being entered into the Excel spread sheet by
the data entry and management team.
Statistical analysis
The cleaned data were exported to Statistical Package for Social Sciences (SPSS) version 25 (IBM Corp.) for analysis. We used
descriptive statistics to compare the hysterectomy types of the
women, and applied the Pearson chi-squared test was used for
categorical variables to determine statistically significant differences between the groups. Statistical significance was accepted
when p-value was <0.05.
Ethical approval
The study was approved by the Ethics Review Board of the
hospital (reference number: 0163/10/2022; date of approval:
1st October, 2022). The study was conducted according to the
Helsinki declarations on ethical principles for medical research
involving human subjects.
Results
A total of 94 hysterectomies were done out of 925 gynecological surgeries within the study period, giving a hysterectomy
rate of 10.2%. Seventy-eight case files were retrieved and used
for this study giving a retrieval rate of 83.0%. Sixty-one (78.2%)
of the cases had abdominal hysterectomy while 17 (21.8%) had
vaginal hysterectomy.
Table 1 shows the biosocial characteristics of these patients.
Abdominal hysterectomy was common between the ages of
40 and 59 years and accounting for 70.5% of the cases while
majority (70.6%) of those that had vaginal hysterectomy were
sixty years and above. The mean age of all the patients who had
hysterectomy was 51.3 ± 8.3 years, while it was 60.0 ± 5.1 years
for those who had vaginal hysterectomy and 48.8 ± 7.4 years for
those who had abdominal hysterectomy. The majority (54.1%)
of abdominal hysterectomies was done between the ages of 40
and 49 years while majority (70.6%) of vaginal hysterectomies
was done from 60 years and above. The age group 50-59 years
was the second most common for both abdominal hysterectomy and vaginal hysterectomy and accounted for 16.4% and
29.4% respectively.
Most (82.4%) of vaginal hysterectomies were done on grand-multiparous women while only 34.4% of abdominal hysterectomies was done on grandmultiparous women. Only 5 (8.2%) of
the woman who had abdominal hysterectomy was nulliparous
while none (0%) of the women who had vaginal hysterectomy
was nulliparous.
Table 2 shows the frequency of the types of hysterectomies.
Majority of the patients (78.2%) had abdominal hysterectomy
while 21.8% had vaginal hysterectomy.
The most common indication for vaginal hysterectomy in this
study was uterovaginal prolapse, which accounted for 100%
(17) of the cases while the commonest indication for abdominal
hysterectomy was uterine fibroids accounting for 54.1% (33) of
the cases. This is shown in table 3.
Table 4 shows the duration of stay in the hospital. The mean
duration of stay in the hospital for all the patients was 10.1 ±
4.2 days, but the patients who had vaginal hysterectomy had a
shorter duration of stay in the hospital. Fourteen (82.4%) of the
patients who had vaginal hysterectomy were discharged within
one week of the surgery while only eight (13.1%) of those who
had abdominal hysterectomy were discharged in the first week
from the hospital. Majority (78.7%) of the patients who had
total abdominal hysterectomy were discharged in the second
week of surgery.
The post operative complications pattern was shown in table
5. Patients who had abdominal hysterectomy developed more
complications than those who had vaginal hysterectomy (44.3%
versus 17.6%) respectively. Primary hemorrhage was seen in six
patients who had abdominal hysterectomy and in two of those
who had vaginal hysterectomy. This was the commonest complication. This is followed by post operative pyrexia which was
present in four patients who had abdominal hysterectomy and
two patients who had vaginal hysterectomy. Thirty four (55.7%)
and 14 (82.4%) of the subjects that had total abdominal and
vaginal hysterectomies respectively had no complication after
surgery. Two (3.3%) mortalities occurred post abdominal hysterectomy while none was recorded following vaginal hysterectomy.
Table 1: Shows the Biosocial Characteristics.
| Age (years) |
Abdominal Hysterectomy n (%) |
Vaginal Hysterectomy n (%) |
| 30-39 |
5 (8.2%) |
0 (0.0%) |
| 40-49 |
33 (54.1%) |
0 (0.0%) |
| 50-59 |
10 (16.4%) |
5 (29.4%) |
| ≥60 |
13(21.3%) |
12(70.6%) |
| TOTAL |
61 (100%) |
17(100%) |
| Parity |
| 0 |
5 (8.2%) |
0 (0%) |
| 01-Apr |
35 (57.4%) |
3 (17.6%) |
| ≥5 |
21 (34.4%) |
14 (82.4%) |
| TOTAL |
61 (100%) |
17 (100%) |
Table 2: Types of hysterectomies.
| Procedure |
Frequency |
Percentage (%) |
| Total Abdominal Hysterectomy (TAH) |
61 |
78.2 |
| Vaginal Hysterectomy |
17 |
21.8 |
| TOTAL |
78 |
100.0 |
Table 3: Indications for Hystrectomy.
| Indication |
TAH |
Vaginal Hysterectomy |
| Utero-vaginal prolapse |
0 |
17 (100.0%) |
| Cervical cancer |
8 (13.1%) |
0 (0.0%) |
| Endometrial Hyperplasia |
5 (8.2%) |
0 (0.0%) |
| Ovarian tumor |
12(19.7%) |
0 (0.0%) |
| Uterine fibroids |
33(54.1%) |
0 (0.0%) |
| Endometrial cancer |
3 (4.9%) |
0 (0.0%) |
| TOTAL |
61 (100%) |
17 (100.0%) |
Table 4: Complication rates and duration of hospital stay following hysterectomy.
| Outcome |
|
TAH |
Vaginal hysterectomy |
| Complications |
None |
34 (55.7%) |
14 (82.4%) |
| Present |
27 (44.3%) |
3 (17.6%) |
| Total |
61 (100.0%) |
17 (100.0%) |
| Hospital stay (days) |
|
≤7 |
8 (13.1%) |
14 (82.4%) |
| 8 – 14 |
48 (78.7%) |
3 (17.6%) |
| ˃ 14 |
5 (8.2%) |
0 |
| Total |
61 (100.0%) |
17 (100.0%) |
Table 5: Complications (outcomes) of the hysterectomies.
| Outcome |
|
TAH |
Vaginal hysterectomy |
| Primary hemorrhage |
None |
55 (90.2%) |
15 (88.2%) |
| Present |
6 (9.8%) |
2 (11.8%) |
| Total |
61 (100%) |
17 (100%) |
| Pyrexia |
None |
57 (93.4%) |
15(88.2%) |
| Present |
4 (6.6%) |
2 (11.8%) |
| Total |
61 (100%) |
17 (100%) |
| Wound infection |
None |
57 (93.4%) |
17 (100%) |
| Present |
4 (6.6%) |
0 (0.0%) |
| Total |
61 (100%) |
17 (100%) |
| Post operation anemia |
None |
58 (95.1%) |
17 (100.0%) |
| Present |
3 (4.9%) |
0 (0.0%) |
| Total |
61 (100.0%) |
17 (100.0%) |
| Wound dehiscence |
None |
59 (96.7%) |
17 (100.0%) |
| Present |
2 (3.3%) |
0 (0.0%) |
| Total |
61 (100.0%) |
17 (100.0%) |
| Death |
None |
59 (96.7%) |
17 (100.0%) |
| Present |
2 (3.3%) |
0 (0.0%) |
| Total |
61 (100.0%) |
17 (100.0%) |
Discussion
A total of 94 gynecological hysterectomies were done out of
925 gynecological surgeries giving a rate of 10.2%. This is similar
to the prevalence reported in Lagos and Sokoto, Nigeria [7,20].
Higher prevalence of 10.7%, 25% and 28% were reported in Nigeria such as in Gombe, Jos and Nnewi respectively [14-16]. The
value is higher than what was found from some other centres in
Nigeria like Kano [2]. Prevalence rates of 25%, 50%, 40-50% and 28% have been reported in United States, France, Australia and
Saudi Arabia respectively [8]. The reduction in the prevalence in
this study when compared with high-income countries could be
due to poor acceptance of hysterectomy in our women as they
often have aversion for surgery, loss of femininity, and sexual
rejection by their spouses, or because of lots of beliefs (cultural, psychosocial and religious) on preservation of menstruation
and childbearing [3,13].
The overall mean age for the women who had hysterectomies was 51.3 ± 8.3 years, while it was 60.0 ± 5.1 years for
vaginal hysterectomy and 48.8 ± 7.4 years for abdominal hysterectomy. This explanation to this could be from the major indications for each procedure (uterovaginal prolapse for vaginal
hysterectomy and leiomyoma for abdominal hysterectomy).
From the study, the hysterectomy was performed commonly on
women who aged 40-49 years. This is comparable to what was
found in other studies in Nigeria [3,12,16].
The mean parity was 4.7 ± 2.3 for all hysterectomies. Most
(82.4%) of vaginal hysterectomies were done on grandmultiparous women while 34.4% of abdominal hysterectomies was
done on grandmultiparous women. Only 5 (8.2%) nulliparous
woman had abdominal hysterectomy while none (0%) of the
nulliparous women had vaginal hysterectomy. The finding was
similar to that reported in Rivers state Nigeria [3]. The high parity noted with vaginal hysterectomy could be due to the fact
that high parity is a predisposing factor for uterovaginal prolapse and this was the most common indication for vaginal hysterectomy in this study.
Abdominal hysterectomy was the commonest hysterectomy done in our facility and accounted for 78.2% while vaginal
hysterectomy accounted for 21.8%. Similar rates of 79.3% and
20.8% were reported in Gombe, Northern Nigeria for abdominal and vaginal hysterectomies respectively [16]. In Kano state,
Nigeria, total abdominal hysterectomy accounted for 93% of gynecological surgeries thus higher than the findings in our centre [2]. Uterine leiomyoma (with or without menorrhagia) and
uterovaginal prolapse were the most common indication for
abdominal hysterectomy and vaginal hysterectomy respectively
in this study. This was comparable to findings reported in Benin
and Lagos, in Nigeria [6,11]. This was in contrast to the work of
Hadi et al; where dysfunctional uterine bleeding was the most
common indication for abdominal hysterectomy [18]. Uterine
leiomyoma is commoner in blacks and majority of the subjects
studied were blacks, hence may be the reason for fibroids being the commonest indication for abdominal hysterectomies.
high-income countries, hysterectomy is done most of the time
to improve the quality of life of the women but this is different
from what obtains in low and middle-income countries where
the uterus is seen as a symbol of womanhood and hence consent for removal of the uterus are difficult to obtain from many
women [5]. Studies from high-income countries have also demonstrated increased acceptance and increased rate of vaginal
hysterectomy over abdominal hysterectomy while the reverse is
the case in low and middle-income countries. In Nigeria, vaginal
hysterectomy is not well utilized as is the case in most low and
middle-income countries despite the obvious benefits of vaginal over abdominal hysterectomies. This is majorly due to the
choice and skills of the surgeons [5].
The overall mean duration of stay in the hospital was 10.1 ± 4.2 days, but those that had vaginal hysterectomy had a less
duration of stay in the hospital. Most of the patients who had
vaginal hysterectomy were discharged within the first week of the surgery while majority of the patients that had total abdominal hysterectomy were discharged in the second week of
surgery. This conforms with studies from both high-income and
low and middle-income countries that vaginal hysterectomy is
associated with less duration of stay in the hospital compared
to abdominal hysterectomy [3-5].
More complications are found in women who had abdominal hysterectomy than in those who had vaginal hysterectomy.
This is comparable to findings from other studies [5,12]. This
could be due to extensive tissue dissection with its associated
morbidity in abdominal hysterectomy when compared with
vaginal hysterectomy. Post operative pyrexia was higher in vaginal hysterectomy subjects. This could be due to high rates of
urinary tract infections which has been found to be higher in
vaginal hysterectomy. The mortality rate for abdominal hysterectomy was 3.3% and none for vaginal hysterectomy. Ovarian
malignancy was responsible for all the mortalities recorded in
this study. Vaginal hysterectomy has been shown to be a safer
procedure as was also reported in other works [2].
Our study is not without limitations. The study design is retrospective in nature. This may have introduced sampling/selection bias and the data may not be representative of whole
population of patients.
Conclusion
From the study, vaginal approach offers good cosmesis, quick
recovery and less operative morbidity. It benefits include quick
recovery, less duration of stay in the hospital, lack of scar and
being minimally invasive. The gold standard for decision making is absence of contraindications and findings on examination.
The number of hysterectomies are low and calls for serious implication for training residents in performing vaginal hysterectomy. This calls for a greater use of other indications other than
genital prolapse. This should not underscore the experience
and proficiency of the surgeon and availability of equipment for
this procedure.
Declarations
Acknowledgements: The authors would like to thank all the
patients whose data were involved in the study. We also thank
all the staff of the hospital involved in this study.
Author contributions: CBO, OOE, CGO and G.U.E were involved in the overall conceptual design and implementation of
the project, and overall revision of the manuscript. C.C.O., EPI,
and COE contributed to data collection, analysis, and manuscript writing. MEN and JII were involved in the writing of this
manuscript and overall revision. The authors read, approved
the final manuscript, and agreed to be accountable for all aspects of the work.
Disclosure statement for publication: All authors have made
substantial contributions to conception and design of the study,
or acquisition of data, or analysis and interpretation of data;
drafting the article or revising it critically for important intellectual content; and final approval of the version submitted. This
manuscript has not been submitted for publication in another
journal.
Declaration of conflicting interests: The author(s) declared
no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the
research, authorship, and/or publication of this article.
Ethical approval and consent to participate: The study was
approved by the Ethics Review Board of the hospital (Reference
number: 0153-/10/2022). Informed consent was not sought for
the present study because it was a retrospective study of cases.
The waiver for the consent was taken from the Institutional Review Board/Ethics Committee.
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