Hysterektomi på benign indikation Daniel Altman Enheten för obstetrik och gynekologi Institutonen för kliniska vetenskaper KI DS

                                                      Daniel Altman 22 september 2018

Daniel Altman 22 september 2018

Daniel Altman 22 september 2018

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 Daniel Altman 22 september 2018

Varför kontrovers? Kelly The effect of hysterectomy on ano-rectal physiology. Int J Colorect Dis 1998;13:116-8. Sood Anorectal dysfunction after surgical treatment for cervical cancer. J Am Coll Surg 2002;195:513-519. Prior Effect of hysterectomy on anorectal and urethrovesical physiology. Gut. 1992;33:264-7. Shorvon Defecography in normal volunteers: results and implications. Gut. 1989;30:1737-49. 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 function two years following hysterectomy or endometrial ablation. Brit J Obstet Gynaecol 1996; 103: 898-903. Daniel Altman 22 september 2018

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 Daniel Altman 22 september 2018

n= 162,488 n= 470,519 STUDIEPOPULATION Slutenvårdsregistret Registret över totalbefolkningen Hysterektomerad cohort n= 162,488 Icke-hysterektomerad cohort n= 470,519 Cancerregistret STUDIEPOPULATION Slutenvårdsregistret Dödsorsaksregistret FoB 1990 Immigrationsregistret Medicinska födelseregistret Daniel Altman 22 september 2018

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) Daniel Altman 22 september 2018

Daniel Altman 22 september 2018

Hysterektomi och inkontinens forts. 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) Daniel Altman 22 september 2018

Hysterektomi och inkontinens forts. Risk for SUI surgery: hysterectomy vs. no hysterectomy Time since surgery 0-5 years 5-10 years >10 years HR (95% CI) 2.6 (2.4-2.8) 2.3 (2.2-2.5) 1.9 (1.8-2.0) Daniel Altman 22 september 2018

Hysterektomi och inkontinens forts. 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) Daniel Altman 22 september 2018

Hysterektomi och inkontinens forts. No hysterectomy Hysterectomy Number of vaginal childbirths HR 95% CI 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 >4 4.7 2.8-7.7 14.2 7.8-25.6 Daniel Altman 22 september 2018

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) Daniel Altman 22 september 2018

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 Daniel Altman 22 september 2018