Catharina Forsgren

Hysterectomy on benign indications in Sweden 1987-2003: a nationwide trend analysis.

Objective. To investigate the annual rates, types and indications for hysterectomy on benign indications in Sweden 1987–2003. Design. A nationwide register‐based cohort study. Setting. The Swedish Inpatient Register. Population. All women hysterectomized for benign disease in Sweden from 1987 through 2003 (n = 121,947). Main outcome measure. Hysterectomy on benign indications calculated as proportions or rates/100,000 person‐years. Results. From 1987 to 1999, the annual overall hysterectomy rate increased from 178 to 232/100,000 person‐years. Thereafter, the overall hysterectomy rate declined and phased out around 210/100,000 person‐years in 2003, a decrease of 11%. Comprising only 4% of hysterectomies performed in 1987, vaginal hysterectomy increased to 31% in 2003. Rates of vaginal hysterectomy by prolapse indication increased by a five‐fold, whereas rates of vaginal hysterectomy by other benign indications increased by a near 20‐fold. Total and subtotal abdominal hysterectomy decreased from 63% and 32%, respectively, in 1987, to 48% and 18% in 2003. Conclusion. The overall rate of hysterectomy on benign indications has remained reasonably stable in Sweden over the last decade. Major trends involved a considerable decrease in rates of abdominal hysterectomy, increased use of vaginal hysterectomy and increased number of hysterectomies performed for pelvic organ prolapse.

Effects of Hysterectomy on Bowel Function: A Three-Year, Prospective Cohort Study

PurposeThis study was a prospective evaluation of the long-term effects of hysterectomy on bowel function using self-reported outcome measures on symptoms of constipation, rectal emptying difficulties, and anal incontinence.MethodsIn this prospective cohort study, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on bowel habits and anorectal symptoms preoperatively. Forty-four patients underwent vaginal and 76 abdominal hysterectomy. Follow-up was performed one and three years postoperatively. Data were analyzed by using multivariate regression and nonparametric statistics.ResultsThe bowel and anorectal survey was answered by 115 of 120 patients (96 percent) after one year and 107 of 120 patients (89 percent) after three years. Abdominal hysterectomy was associated with increased anal incontinence symptoms at one-year (P < 0.01) and three-year follow-up (P < 0.01). Vaginal hysterectomy was not associated with increased anal incontinence symptoms at one year follow-up, although there was a significant increase in incontinence symptoms at the three-year follow-up (P < 0.05). Risk factor analysis indicated that a reported history of obstetric sphincter injury was correlated to an increased risk of developing posthysterectomy anal incontinence (odds ratio, 2.07; 95 percent confidence interval, 1.05–2.87; P < 0.05). There was no significant rise in constipation symptoms or rectal emptying difficulties in either cohort through the follow-up.ConclusionsNeither abdominal nor vaginal hysterectomy was associated with constipation, aggravation of constipation, or rectal emptying difficulties three years after surgery. Abdominal and vaginal hysterectomy was, however, associated with an increased risk of mild anal incontinence symptoms, and patients with a reported history of obstetric sphincter injury were at particular risk for posthysterectomy fecal incontinence.

Risk of pelvic organ fistula in patients undergoing hysterectomy.

Purpose of review To summarize and describe present knowledge regarding the incidence, cause and risk factors of pelvic organ fistula related to hysterectomy. Recent findings The reported incidence of pelvic organ fistula after hysterectomy ranges from 0.1 to 4% in different studies, and a higher incidence is generally reported after radical hysterectomy compared with hysterectomy on benign indications. Iatrogenic injury to the urinary tract or bowels during surgery, and postoperative infections, are probably the main etiologic factors involved in the pathogenesis of fistula formation subsequent to hysterectomy. Evidence from observational studies suggests that hysterectomy increases the risk for pelvic organ fistula disease compared with women with an intact uterus and that risk factors include laparoscopic and total abdominal hysterectomy, increasing age, smoking, diverticulitis and pelvic adhesions. Summary In industrialized countries, where pelvic organ fistula is rare owing to advances in modern obstetric care, hysterectomy is an important cause of fistula disease. This review demonstrates that hysterectomy is associated with pelvic organ fistula and describes a number of predisposing factors. Although rarely encountered in a general population, pelvic organ fistula disease may have a devastating effect on all aspects of quality of life and should be considered in the surgical decision at the time of hysterectomy.

Hysterectomy for Benign Indications and Risk of Pelvic Organ Fistula Disease

OBJECTIVE: To study the association between hysterectomy for benign indications and pelvic organ fistula disease. METHODS: We conducted a nationwide cohort study based on Swedish health care registers. The cohort consisted of 182,641 women having hysterectomy (exposed cohort) and 525,826 women not undergoing the procedure (unexposed cohort) from the Swedish Inpatient Register 1973–2003. The outcome was defined as surgery for pelvic organ fistula disease. We calculated incidence rates for fistula disease and hazard ratios (HRs) with 95% confidence intervals (CIs) as a measure of relative risk. RESULTS: We identified 853 cases of pelvic organ fistula surgery: 469 among the exposed women and 384 among the unexposed. The overall rate of fistula surgery was four times higher in the exposed compared with the unexposed cohort (rate 23.8 and 6.3 per 100,000 person-years, respectively). Overall number needed to harm was 5,700. Compared with unexposed, the risk for fistula disease was more than 20 times higher the first year after surgery (HR 21.2, 95% CI 14.9–30.2). The most common type of fistula was intestinogenital fistula (404 cases, 47%), followed by urogenital fistula (220 cases, 26%). Laparoscopic hysterectomy was associated with the highest rate of fistula surgery, and subtotal abdominal hysterectomy was associated with the lowest (rate 95.9 and 13.7 per 100,000 person-years, respectively). CONCLUSION: Pelvic organ fistula surgery is four times more common in women after hysterectomy compared with women not having the procedure. The highest fistula rates were observed the first year after surgery, after laparoscopic and total abdominal hysterectomy, and among older women. LEVEL OF EVIDENCE: II

Vaginal hysterectomy and risk of pelvic organ prolapse and stress urinary incontinence surgery

Introduction and hypothesisThis study aims to determine the risk of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery related to mode of hysterectomy focusing on vaginal hysterectomy.MethodsWe performed a nationwide cohort study. Women exposed to hysterectomy on benign indications (n = 118,601) were compared to women unexposed to hysterectomy (n = 579,200). The outcome was defined as first occurrence of POP or SUI surgery. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs) using Cox proportional-hazards models.ResultsThe greatest risks of POP (HR 4.9, 95% CI 3.4–6.9) or SUI surgery (HR 6.3, 95% CI 4.4–9.1) were observed subsequent to vaginal hysterectomy for pelvic organ prolapse. Having a vaginal hysterectomy for other reasons also significantly increased the risks of POP and SUI surgery compared to other modes of hysterectomy.ConclusionsHysterectomy in general, in particular vaginal hysterectomy, was associated with an increased risk for subsequent POP and SUI surgery.

Influence of hysterectomy on fistula formation in women with diverticulitis

Diverticulitis is a risk factor for fistula formation but little is known about the influence of hysterectomy in this association. A population‐based nationwide matched cohort study was performed to determine the risk of fistula formation in hysterectomized women with, and without, diverticulitis.