Increasing use of laparoscopic hysterectomy: we need to talk about outcomes

摘要

This paper by Madhvani et al. (BJOG 2019; 126:795–802) illustrates clearly how much can be learned about gynaecological practice from a simple analysis of administrative hospital data. Their results show a more than two-fold increase in the proportion of hysterectomies for benign and malignant conditions that were carried out laparoscopically over a recent 6-year period in the English National Health Service (NHS). At the same time, one could argue that there is an ‘elephant in the room’: there is no information about outcomes, which would have addressed some of the ongoing concerns about the safety and short-term outcomes of laparoscopic procedures (Heavy Menstrual Bleeding: Assessment and Management. NICE, 2018, https://www.nice.org.uk/guidance/ng88/chapter/Recommendations). It is therefore important to interpret the findings of Madhvani et al. combined with those published elsewhere. For example, a recent report published by the Royal College of Obstetricians and Gynaecologists (Patterns of Benign Gynaecology Care in English NHS Hospital Trusts 2015/16. RCOG, 2018, https://www.rcog.org.uk/globalassets/documents/guidelines/research-audit/benign-gynae-indicators-report-2015-16.pdf), using the same type of data, demonstrated that women who underwent a hysterectomy for a benign indication in the English NHS between April 2015 and March 2016 had a considerably shorter length of stay with a laparoscopic hysterectomy (12.8% spent at least 2 nights in hospital) than with an open abdominal procedure (corresponding figure 55.8%). The same report showed that there is little difference between the 30-day emergency readmission rate after laparoscopic hysterectomy (4.9%) and abdominal procedure (5.5%). However, the paper by Madhvani et al. does provide some information about the success of the laparoscopic approach during a period of rapid uptake. The proportion of procedures that began with a laparoscopic approach but were converted to an open approach seemed to have gone down over the study period. For example, based on the results presented in Table 1, about 11% (1.6/ 14.8%) of the laparoscopic hysterectomies carried out in 2011 for fibroids were converted to open approaches, whereas the corresponding percentage for 2017 was about 8% (2.5/31.9%). There is a similar decrease in the percentage of failed laparoscopic hysterectomies between 2011 and 2017 for all indications. I would interpret these findings as evidence that laparoscopic surgery has become more successful, which is in stark contrast to the interpretation by Madhvani et al., who fail to interpret the increased number of failed laparoscopic procedures in the context of the rise in the total number of laparoscopic procedures. Further work is required to build upon this analysis of an existing national dataset. For example, analyses of the rapid uptake of robotic surgery for hysterectomy (Marcus et al. Int J Med Robotics Comput Assist Surg 2017;13:e1870), longer term outcomes, the learning curve related to the introduction of new surgical techniques, and the health service implications of investments in innovative procedures (Aggarwal et al. Lancet Oncol 2017;18:1445–53) can provide more insights into the implications of changing approaches to hysterectomy. International comparisons would add even more value, of relevance for the evaluation of gynaecological practice and the development of clinical guidelines. None declared. Completed disclosure of interests form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.