Reviewer's report 
 Hysterectomy at a Canadian Tertiary Care Facility: Results of a One-Year Retrospective Title: 
Review 
 1  12 May 2004 Version: Date: 
 s. robert kovac Reviewer: 
Reviewer's report: 
1. The stated purpose of this retrospective review of all hysterectomies over a one year period at a 
teaching hospital to identify areas for improvement. The impetus for this study appears to relate to The Society of Obstetricans and Gynecologists of Canada (SOGC) Clinical Practice Guidelines 
which recommend offering VH to all women where that approach is deemed feasible by the surgeon. 
In addition, the Ontario Hospital Asssociation has identified the ratio of vaginal to abdominal 
hysterectomy as a measure of hospital performance, with a more favorable grade awarded to those hospitals with higher proportion of VH?s. 2. There have been only a few articles that focus on peri and postoperative complications of 
hysterectomy, regardless of the route of the operator. Themajority of hysterectomies were AH 
(78%), 14% were VH, and 5.9% were LAVH. Fifty-eight (15.6%) of patients had a diagnosis of cancer preoperatively which would be considered an indication for AH. In the United States data published by the National Center for Health Statstics Hospital Discharge Survey for 1997, 8.3% of 
hysterectomies were performed for malignant disease while 91.7% were done for benign conditions. 
Sixty-four and one-half percent were done through the abdominal route and 35.5% were done 
transvaginally without laparoscopic assistance. Laparoscopic assistance was used in 19% of cases 
when the route was vaginal. The predominance of the abdominal route in this study and in the 
National statistics in the United States remains puzzling despite the well documented benefits of VH 
in terms of lower complication rates, shorter length of stay and convalescence, lower hospital 
charges, and more favorable quality-of-life outcomes, including reduced mortality. 3. The authors state the purpose of the study was to investigate the indications for an approach to 
hysterectomy but they do not address sufficiently the reasons why certain indications require a 
certain method to be was selected. 4. In addition, they wanted to examine the circumstances in which concurrent oopherectomies were performed as well as to compare abdominal and vaginal hysterectomy outcomes. They do not 
address why oopherectomies were more frequently performed abdominally in their study. 
5. Furthermore, it is impossible to compare the outcomes of abdominal and vaginal hysterectomy since the indications fore each type of hysterectomy are not comparable. The most frequent 
indication for hysterectomy was dysfunctional uterine bleeding. If they were to compare the results of 
abdominal and vaginal hysterectomy for this indication, the outcomes for this indication done 
abdominally or vaginally would have considerable meaning. Matched variables can be statistically measured. Unmatched variables can not. Concurrent procedure performed at the time of hysterectomy also can not be compared to hysterectomy alone. The real issue for selecting 
abdominal hysterectomy for dysfunctional uterine bleeding needs to be understood, as there are few 
contraindications of uterine enlargement or extrauterine conditions for this indication that would not suggest the vaginal approach would not be feasible. Dysfunctional uterine bleeding has always been one of the most common indications for which vaginal hysterectomy is performed. The pathologic 
weight of uteri for this indication would be most helpful for the reader to determine whether this was 
the factor responsible for the frequent selection of the abdominal route. 
7. The authors offer an frequent justification for determining the route of hysterectomy by suggesting 
that this study documents that surgeon expertise and the need for adnexal surgery may play the 
strongest role in determining the ultimate route for hysterectomy. Although many early studies on 
hysterectomy offer this as an explanation for the predominant use of abdominal route, this was not 
documented in this study. Recent articles in the United States that have studied the decision-making 
processes for determining the route of hysterectomy have shown that it is not the clinical indication 
or the surgeons expertise directly but the comfort and preference of the surgeon to select the abdominal route. If this is true for surgeons in Canada, the recommedation by the SOGC to allow surgeons to determine whether or not the vaginal approach is feasible will not change the 
predominant use of the abdominal route. Could the authors respond to this. 
8. The authors also state that the general trend in determining the route of hysterectomy has been to challenge the validity of the exclusionary criteria for VH, such as nulliparity, larger uterine size, previous Cesarian delivery, and pelvic laparotomy. They continue by stating that these are no longer 
considered strong contraindications to the vaginal approach. The reader is left to try and understand 
why then was AH selected in most of the cases in their study, as it is unclear whether any of the 
surgeons stated reasons why these conditions affected the route of hysterectomy in this study. 
9. They also suggest that obesity of the buttocks may interfere with the exposure necessary for VH, 
but the references supporting that statement do not suggest that. They must check the references 
used to support this contention. 10. The authors report that 275 oopherectomies were performed with AH and 52 with VH and suggest that adnexal removal may be a factor in the less frequent use of VH. Could this be a result 
of the influence of the United Kingdom where for years it was believed that removal of the ovaries 
demanded a AH. There are over 25 studies in the literature today that report on successful 
transvaginal removal of the ovaries in over 94% -97% attempted. A statement is required to explain. 
11. Since the most frequent indication for hysterectomy was dysfunctional uterine bleeding, the 
authors need to address why this indication was most frequently performed by the abdominal route. 
The fact that physician attitude fostered in training may dominate clinical considerations is found in 
several revealling studies. They reference one study of hysterectomy practice in a 5-year period at a 
district hospital in the United Kingdom, where a mandate was issued to carry out as many 
hysterectomies as possible by the vaginal route. In the 5-years after the mandate, the percentage of 
abdominal and vaginal hysterectomies changed from 68% and 32% to 5% and 95%, respectively. If gynecologic surgeons can achieve such a conversion, it is logical to assume that Canadian surgeons can do likewise. In the United States a center has reported such a transformation by 
applying the Guidelines of the Society of Pelvic Reconstructive Surgeons(www.guidelines.gov). In 
fact, these guidelines have been field tested in seven countries and have shown a marked reduction 
in AH. These guidedlines formed the basis of a flow chart designed to facilitate the determination of 
whether a transvaginal or abdominal hysterectomy is mandated. 
12. The authors conclude that a significant reduction in length of stay was found using the vaginal 
approach, a frequent finding in most articles comparing AH and VH This statement along with the statements from the SOGC and the OHA seem to indicate a desire to improve the numbers of VH performed. I might suggest that the adoption of the guidelines of the Society of Pelvic 
Reconstructive Surgeons (www.guidelines.gov) would assist them in achieving that goal. I would 
welcome a report from the authors on the outcomes of such an adoption. 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Acceptable Quality of written English: 
 Yes Statistical review: