Hysterectomy: The Evidence

HysterectomyThe Evidence

Anusch YazdaniMBBS (Hons) FRANZCOG CREI

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Declaration of Interest• Appointments

• Director, Eve Health Australia• Clinical Director of Research and Education, QFG • Clinical Director, Reproductive Endocrinology and Infertility, RBWH• Program Director, Reproductive Endocrinology and Infertility (CREI)• Vice President, Australasian Gynaecological Endoscopy & Surgery Society (AGES)• Councillor, RANZCOG• Associate Professor, University of Queensland• Consultant, AHPRA

• Educational Third Party Funding• MSD• Merck-Serono• Ferring• AGES Society Research Foundation

• Financial Disclosure• Minority shareholder Virtus Health

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NHMRC Levels of Evidence

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Systematic Review

(Cochrane)

Randomised Controlled Trial

Pseudorandomised Trial

Controlled Comparative Study

Uncontrolled Comparative Study

Case Series or Report

NHMRC Levels of Evidence

Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub4

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Laparoscopic vs Vaginal: OT Time

Cochrane Sys Rev 2009, 3: CD003677

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Laparoscopic vs Abdominal: OT Time


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Laparoscopic vs Abdominal: Complications


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Laparoscopic vs Vaginal: Complications


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Laparoscopic vs Vaginal : Recovery


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Laparoscopic vs Abdominal: Recovery


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Laparoscopic vs Abdominal: Satisfaction


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Robotic Hysterectomy: Complications


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Robotic Hysterectomy: Haemorrhage


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Robotic Hysterectomy: OT Time


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Robotic Hysterectomy: Inpatient


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Robotic Hysterectomy: Recovery


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Robotic Hysterectomy: Cost


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Summary of Evidence• Vaginal Hysterectomy

• every one should have one• Laparoscopic Hysterectomy

• takes longer• higher risk of transfusion• higher risk intraoperative injury• more postoperative pain• slower recovery• no benefit in long term recovery

• Abdominal Hysterectomy• no way • but if you have to, your patients will be happy that you didn’t

damage anything and after 6 months none of them will care• Robotic Hysterectomy

• you’ve got to be kidding

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Hysterectomy Modality

2006 2007 2008 2009 2010 2011 2012 2013 20140

1,000

2,000

3,000

4,000

5,000

6,000

Abdominal Vaginal LH

VH: 39%LH: 36%

AH: 25%

VH: 42%

AH: 36%

LH: 22%

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Hysterectomy Modality

2006 2007 2008 2009 2010 2011 2012 2013 20140

1,000

2,000

3,000

4,000

5,000

6,000

Abdominal Vaginal LH

why?Robotic

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Scientific Method

NaHCO3 + HCl NaCl + H2O + CO2

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Scientific Method

NaHCO3 + HCl NaCl + H2O + CO2truth

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Scientific Method

• the truth is out there• the truth is absolute

• the truth can be determined by applying the appropriate scientific method• hypothesis• test hypothesis• prospective randomised double blind controlled trial

• modify hypothesis

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Scientific Method

NaHCO3 + HCl NaCl + H2O + CO2truth

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Scientific Method

NaHCO3 + HCl NaCl + H2O + CO2x

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Scientific Method


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Scientific Method


TRUTH

TRUTHtruth

truth truth

Truth

TRUTH

truth

truthtruth

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Scientific Method


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Summary of Evidence• Vaginal Hysterectomy

• every one should have one• Laparoscopic Hysterectomy

• takes longer• higher risk of transfusion• higher risk intraoperative injury• more postoperative pain• slower recovery• no benefit in long term recovery

• Abdominal Hysterectomy• no way • but if you have to, your patients will be happy that you didn’t

damage anything and after 6 months none of them will care• Robotic Hysterectomy

• you’ve got to be kidding

only if your patient does not have prolapse, urinary incontinence, fibroids, adenomyosis, endometriosis, large uterus (more than 10 weeks), anaemic, iron deficient or any other medical condition or has had previous abdominal surgery

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Worldviews (Epistomologies)Postpositivism ConstructivismDeterminationReductionismObservation and measurementTheory verification

UnderstandingMultiple participant meaningSocial constructionTheory generation

Transformative PragmatismPoliciticalPower and justice orientationCollaborativeChange orientated

ConsequencesProblem centredPluralisticReal world orientated

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The Cochrane Problem

• time• mean time 23 months• hundreds of man hours• 2012: 35% of reviews up to date

The Cochrane Oversight Committee. Measuring the performance of The Cochrane Library. 2012 Allen IE, Olkin I. Estimating time to conduct a meta-analysis from number of citations retrieved.

JAMA. 1999 Aug 18;282(7):634-5

• methodology• intention to treat analyses• RCTs only assessed

• each RCT is narrow• limited generalisability

• aggregate not individual patient data (IPD) • heterogeneity

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Conclusion

evidence based medicine = systematic review & meta-analysis

understand the limitations of the scientific method

understand the environment in which you work

/

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Conclusion

no modality is inherently correct or incorrect

the correct hysterectomy is the modality chosen in partnership with your patient taking into consideration her circumstance &

pathology and your training & resources

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Hysterectomy: The Evidence

Health & Medicine

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