Key words hysterectomy - complications - satisfaction - length of hospital stay
Schlüsselwörter Hysterektomie - Komplikationen - Zufriedenheit - Verweildauer im Krankenhaus
Abbreviations
aOR:
adjusted odds ratio
ASA:
the American Society of Anesthesiologistsʼ classification of physical status
BMI:
body mass index
CI:
confidence interval
GynOp:
the Swedish National Register for Gynecological Surgery
LOS:
length of hospital stay
OR:
odds ratio
SD:
standard deviation
Introduction
Hysterectomy performed on benign indication is the most common major gynecological
procedure [1 ]. Hysterectomy may be accomplished either by removing the entire uterus (total hysterectomy)
or retaining the cervical part (subtotal hysterectomy) using an abdominal or minimally
invasive (laparoscopic or vaginal) approach [2 ].
More than 90% of women report a high satisfaction rate several years following hysterectomy,
irrespective of surgical approach or technique [1 ], [3 ], [4 ]. High levels of satisfaction are correlated with improvements in symptoms, such
as abnormal uterine bleeding or mechanical symptoms of myoma. Pelvic pain or endometriosis
as indication of hysterectomy can be associated with greater dissatisfaction of the
result of surgery [5 ].
However, risk factors for an adverse outcome following hysterectomy in patient-reported
measures have rarely been reported in the literature. It seems crucial to focus on
achievement of the goals of surgery in a patient perspective, to gain a more patient-centered
health care. Moreover, the association between the appearance and degree of intra-
and postoperative complications following hysterectomy and the perceived satisfaction
rate has not been particularly studied [5 ], [6 ], [7 ].
Intra- and postoperative complications may occur whatever surgical technique or approach
is used, although complications seem less frequent following minimally invasive surgery
(around 10% for vaginal hysterectomy, up to 20% reported for abdominal hysterectomy)
[3 ], [4 ]. It seems reasonable to believe that adverse events associated with hysterectomy
could affect the womanʼs satisfaction with the result of surgery.
The aim of this retrospective register study was to evaluate the impact of intra-
and postoperative complications on the perceived satisfaction and self-reported assessment
of the medical condition one year after hysterectomy on benign indications, and to
determine risk factors for adverse outcomes in these measures. A secondary aim was
to analyze whether complications occurring at different times during and after the
hospital stay were associated with the length of hospital stay (LOS).
Material and Methods
Study design
This study consists of retrospective data from the Swedish National Register for Gynecological
Surgery (GynOp) [8 ], on the cohort of women undergoing hysterectomy for benign conditions between January
2004 and June 2016. Exclusion criteria were postmenopausal women or women more than
55 years of age, present adnexal tumor, dysplasia, prolapse or urinary incontinence
as main indication for surgery, indication or mode of surgery unclear, preventive
or pregnancy-related surgery, and present chronic infectious diseases. More than 75%
of women undergoing hysterectomy on benign indications participate in the GynOp [8 ].
All women received written information about the register before surgery, and could
decline to participate if desired. Both women and physicians were involved in the
data collection process. The women completed a health declaration form and answered
questions about subjective symptoms preoperatively. Preoperative expectation of surgery
was asked for and the women had three alternative answers to the question: Get rid
of symptoms, Be relieved of symptoms or No expectations of surgery. The gynecologist
who performed the preoperative assessment completed a form about preoperative objective
findings. The surgeon recorded information about surgery in connection with the operation.
The gynecologist filled out a postoperative form concerning the postoperative course
at discharge. The day of surgery and discharge from hospital were registered, which
enabled calculation of LOS.
Eight weeks and one year postoperatively the women received an inquiry questionnaire
regarding health status, opinions covering recovery and experiences of surgery, any
adverse advents, satisfaction with surgery, and their current medical condition in
relation to outcome of surgery. In addition, the gynecologist reviewed and evaluated
all inquiry forms to obtain the most correct data [8 ]. All information from the women and the gynecologistʼs evaluation were recorded
in the register.
Data collection
Assembled data included:
demographics from health declaration form: age, parity, height and weight, (enables
calculation of body mass index [BMI]), smoking habits, and womenʼs preoperative expectations
of surgery;
clinical data accumulated peri- and postoperatively: the American Society of Anesthesiologistsʼ
classification (ASA), main indications of surgery categorized in four groups (menstrual
disorder, uterine myoma, pain-related or other indications (premenstrual tension syndrome,
hormone therapy related problems other than bleeding disorder, cervical stenosis and
hematometra, chronic cervicitis, complications with intrauterine device, and urinary
dysfunction related to the uterus), surgical technique (subtotal/total) and approach
(at conclusion of surgery, that is abdominal or minimally invasive [laparoscopic or
vaginal]), whether the woman had any remaining ovary at conclusion of surgery, complications
during hospital stay;
from the eight-week inquiry form: occurrence of complications after discharge, and
information from the one-year inquiry form covering questions about occurrence of
complications from eight weeks postoperatively up to one year, and rating of medical
condition at present, and contentment with the result of surgery. The questions (Q)
and options for possible answers (A) in the inquiry forms are presented in [Fig. 1 ].
Fig. 1 Questions (Q) and options for possible answers (A) in the inquiry forms from the
GynOp.
Missing data
The women who underwent surgery less than one year prior to the data retrieval did
not have the possibility to answer the one-year questionnaires. Moreover, some of
the questions in the inquiries have changed over time. Thus, there will be missing
data for some of the items. The question in the preoperative inquiry form concerning
the patientʼs expectation of the surgery (get rid of the symptoms; be relieved, or
do not have expectations) was excluded in 2013 and the one-year inquiry form concerning
medical condition was included 2007 and concerning result of surgery in 2010. The
one-year inquiry questionnaire was optional. All except one region in Sweden systematically
sent the form to all participating women. The response rate of the one-year inquiry
form was consequently determined as the proportion of women answering the inquiry
form of those who de facto received the form.
Classification of complications
The GynOp has classified complications as mild or severe. Severe complications, which
are equivalent to major complications, were defined as thromboembolism, all injuries
to the bladder, ureter, bowel, or major vascular structures, fistula, bleeding of
more than 3000 ml, any reason making a re-operation necessary, hospitalization for
more than seven days, persistent physical handicap or death of the patient. Furthermore,
septic postoperative infections, and any other major complication (i.e. aspiration,
allergic shock, myocardial infarct, or cerebral complication) also constitute severe
complications [9 ]. Mild complications are equivalent to minor complications, and were defined as adverse
events that did not have the severity of major complications for example urinary tract
infections and wound complications/infections.
Statistical analyses
The software Statistica v 13.2 (Dell Software, 5 Polaris Way, Aliso Viejo, CA 92656,
USA) was used for the statistical analyses.
Data are presented as mean and one standard deviation (SD) or number and per cent.
Continuous data were analyzed by means of one-way ANOVA or Studentʼs t-test, and categorical
data by means of χ2 test for trends. Analyses of LOS in relation to complications were performed by means
of ANCOVA models adjusted for BMI, smoking habits, and occurrence of complications
developed prior to the occasion of evaluation. Post hoc tests were evaluated by means
of Tukeyʼs honest significant difference tests.
In order to assess the impact of various factors on outcome measures of PREM and PROM,
multivariable logistic regression models were assessed. The dependent variable medical
condition was dichotomized in “improved or much improved” versus “unchanged, worse
or much worse”. Likewise was the opinion about the result of the surgery one year
postoperatively dichotomized in “satisfied or very satisfied” versus “neither satisfied
nor dissatisfied”. Multivariable logistic regression models were adjusted for known
or potential confounding factors. The confounding factors (age, BMI [as a continuous
variable], smoking, indication and mode of hysterectomy and having a remaining ovary
postoperatively) were entered simultaneously into the models. Results are presented
as crude and adjusted odds ratios (ORs or aORs) and 95% confidence intervals (CI).
The significance level was set at p < 0.05.
Ethical approval
The study was approved by the Regional Ethics Board of Linköping University (Reg.
nr. M19–07; amendment 2016/66-32).
Results
Study population
[Fig. 2 ] presents a flow chart of the study population.
Fig. 2 Flow chart demonstrating the selection of the study population of women undergoing
hysterectomy.
Demographic, descriptive and clinical characteristics subdivided according to mode
of surgery at conclusion of the operation are demonstrated in [Table 1 ]. The number of missing data is presented in [Tables 2 ] and [3 ] in connection with each variable and varies from a few per cent to a larger proportion;
in the latter case mostly due to the limitation in use over time of the item in the
inquiry forms. Five hundred and thirty-six of those who were originally scheduled
for a minimally invasive procedure, 282 (4.4%) laparoscopically and 254 (7.1%) vaginally,
were intraoperatively converted to abdominal hysterectomy.
Table 1 Demographic, descriptive and clinical data of 27 938 women undergoing hysterectomy
for benign conditions in relation to mode of surgery (at conclusion of the operation).
By laparotomy
By minimally invasive technique
Characteristics
Total hysterectomy
n = 13 709 (49.1%)
Subtotal hysterectomy
n = 4774 (17.1%)
Laparoscopic hysterectomy
n = 3337 (11.9%)
Vaginal hysterectomy
n = 6118 (21.9%)
Total hysterectomy
n = 2878 (10.3%)
Subtotal hysterectomy
n = 459 (1.6%)
Figures denote mean and ± one standard deviation (SD) or number and (%) on obtainable
data for each characteristic.
ASA – the American Society of Anesthesiologistsʼ classification of physical status;
BMI – body mass index.
* Pelvic pain/dyspareunia/dysmenorrhea/endometriosis. § Data not available in the period 2013 – 2016.
Age (years)
45.6 (5.1)
45.5 (5.0)
44.6 (5.4)
45.1 (4.9)
44.4 (5.1)
BMI (kg/m2 )
26.4 (4.6)
26.8 (5.0)
26.1 (4.7)
25.2 (4.4)
26.1 (4.7)
Parity
2.1 (1.2)
2.1 (1.2)
2.1 (1.2)
1.9 (1.1)
2.5 (1.1)
Smoking (no. of women):
1991 (14.5%)
686 (14.4%)
357 (12.4%)
33 (7.2%)
1011 (16.5%)
8833 (64.4%)
3316 (69.4%)
1594 (55.4%)
154 (33.5%)
3595 (58.8%)
2885 (21.1%)
772 (16.2%)
927 (32.2%)
272 (59.3%)
1512 (24.7%)
Indication of hysterectomy:
7737 (56.4%)
2978 (62.4%)
1560 (54.2%)
147 (32.0%)
4352 (71.1%)
2522 (18.4%)
717 (15.0%)
146 (5.1%)
18 (3.9%)
174 (2.8%)
1542 (11.3%)
481 (10.1%)
499 (17.3%)
33 (7.2%)
498 (8.1%)
130 (0.9%)
48 (1.0%)
36 (1.3%)
0 (0%)
10 (0.2%)
1778 (13.0%)
550 (11.5%)
637 (22.1%)
261 (56.9%)
1084 (17.7%)
ASA:
13 197 (96.3%)
4600 (96.4%)
2779 (96.6%)
450 (98.0%)
5965 (97.5%)
208 (1.5%)
67 (1.4%)
49 (1.7%)
4 (0.9%)
52 (0.8%)
304 (2.2%)
107 (2.2%)
50 (1.7%)
5 (1.1%)
101 (1.7%)
Operating time (min)
100 (41)
83 (35)
116 (47)
96 (43)
66 (31)
Uterus weight (g)
533 (523)
487 (436)
229 (146)
243 (174)
192 (123)
Estimated perioperative bleeding volume (ml)
327 (349)
273 (307)
132 (162)
127 (135)
137 (147)
Remaining at least one ovary postoperatively:
11 136 (81.2%)
4125 (86.4%)
2032 (70.6%)
199 (43.4%)
4770 (78.0%)
1012 (7.4%)
167 (3.5%)
258 (9.0%)
3 (0.6%)
29 (0.5%)
1561 (11.4%)
482 (10.1%)
588 (20.4%)
257 (56.0%)
1319 (21.5%)
Preoperative expectation of surgery:
4871 (35.5%)
2188 (45.8%)
387 (13.5%)
104 (22.7%)
2276 (37.2%)
1462 (10.7%)
629 (13.2%)
166 (5.8%)
29 (6.3%)
592 (9.7%)
200 (1.5%)
64 (1.3%)
13 (0.4%)
1 (0.2%)
42 (0.7%)
7176 (52.3%)
1893 (39.7%)
2312 (80.3%)
325 (70.8%)
3208 (52.4%)
Table 2 Occurrence and classification of complications intra- and postoperatively after hysterectomy
in relation to surgical mode.
By laparotomy
By minimally invasive technique
Complications reported
Total hysterectomy
n = 13 709 (49.1%)
Subtotal hysterectomy
n = 4774 (17.1%)
Laparoscopic hysterectomy
n = 3337(11.9%)
Vaginal hysterectomy
n = 6118 (21.9%)
Total hysterectomy
n = 2878 (10.3%)
Subtotal hysterectomy
n = 459 (1.6%)
Figures denote number of women and percent.
§ Missing data are indicated for the entire group. Only 80% received the 1-year postoperative
inquiry form; consequently the missing data will constitute a high proportion.
Intraoperatively:
12 982 (94.7%)
4589 (96.1%)
2790 (96.9%)
452 (98.5%)
5937 (97.0%)
532 (3.9%)
148 (3.1%)
60 (2.1%)
6 (1.3%)
136 (2.2%)
173 (1.3%)
35 (0.7%)
13 (0.5%)
1 (0.2%)
30 (0.5%)
22 (1.1%)
2 (0.1%)
15 (0.5%)
0 (0.0%)
15 (0.3%)
After surgery, during hospital stay:
12 178 (88.8%)
4312 (90.3%)
2676 (93.0%)
441 (96.1%)
5635 (92.1%)
985 (7.2%)
310 (6.5%)
136 (4.7%)
12 (2.6%)
303 (4.9%)
332 (2.4%)
85 (1.8%)
41 (1.4%)
5 (1.1%)
132 (2.2%)
214 (1.6%)
67 (1.4%)
25 (0.9%)
1 (0.2%)
48 (0.8%)
Within eight weeks after discharge:
8326 (60.7%)
3286 (68.8%)
1695 (58.9%)
244 (53.2%)
4096 (67.0%)
2474 (18.0%)
651 (13.6%)
385 (13.4%)
38 (8.3%)
783 (12.8%)
460 (3.4%)
84 (1.8%)
90 (3.1%)
6 (1.3%)
179 (2.9%)
2449 (17.9%)
753 (15.8%)
708 (24.6%)
171 (37.2%)
1060 (17.3%)
Between eight weeks and one year:
7607 (55.5%)
3044 (63.8%)
1147 (39.9%)
159 (34.6%)
3639 (59.5%)
1097 (8.0%)
313 (6.5%)
128 (4.4%)
10 (2.2%)
286 (4.7%)
229 (1.7%)
41 (0.9%)
34 (1.2%)
2 (0.4%)
68 (1.1%)
4776 (34.8%)
1376 (28.8%)
1569 (54.5%)
288 (62.8%)
2125 (34.7%)
Table 3 Complications intra- and postoperatively after hysterectomy on various occasions
until one year postoperatively in relation to dichotomized self-reported perception
of medical condition/result of surgery.
Medical condition
Result of surgery
Received the specific question (n = 20 301)
Received the specific question (n = 24 443)
Reported§ (n = 12 506 [61.6%])
Reported§ (n = 17 714 [72.5%])
Occasion of report/complication grade
Improved or much improved
Unchanged, worse or much worse
Satisfied or very satisfied
Neither satisfied or dissatisfied
Figures denote number of women and percent.
# Data about complication or grade of complication not stated in the register at discharge
from the hospital after surgery.
§ The number of participants who have completed the one-year follow-up questionnaire
or the specific question in the form.
Intraoperatively:
11 542 (95.6%)
529 (4.4%)
15 717 (92.7%)
1236 (7.3%)
308 (96.0%)
13 (4.0%)
537 (91.3%)
51 (8.7%)
94 (95.0%)
5 (5.0%)
111 (81.0%)
26 (19.0%)
13 (86.7%)
2 (13.3%)
33 (91.6%)
3 (8.4%)
After surgery, during hospital stay:
10 837 (95.8%)
475 (4.2%)
14 798 (93.1%)
1100 (6.9%)
734 (93.6%)
50 (6.4%)
1077 (89.2%)
130 (10.8%)
227 (93.8%)
15 (6.2%)
286 (80.5%)
69 (19.5%)
159 (94.6%)
9 (5.4%)
237 (93.3%)
17 (6.7%)
8-weeks questionnaire:
8851 (96.7%)
301 (3.3%)
12 077 (94.6%)
687 (5.4%)
2020 (93.0%)
151 (7.0%)
2780 (88.2%)
371 (11.8%)
325 (87.8%)
45 (12.2%)
413 76.6%)
126 (23.4%)
761 (93.6%)
52 (6.4%)
1128 (89.5%)
132 (10.4%)
1-year questionnaire:
10 192 (96.8%)
337 (3.2%)
14 166 (94.9%)
755 (5.1%)
1046 (90.4%)
111 (9.6%)
1354 (80.6%)
327 (19.4%)
169 (80.1%)
42 (19.9%)
201 (60.5%)
131 (39.5%)
550 (90.3%)
59 (9.2%)
677 (86.8%)
103 (13.2%)
Complications
Prevalence and degree of severity of complications in relation to the occasion of
reporting the complication and to modes of hysterectomy are shown in [Table 2 ]. In total, 67.9% (11 132/16 388) reported a completely complication-free hysterectomy
within the first year postoperatively.
[Table 3 ] shows the self-reported perception of medical condition and opinion of result of
surgery one year postoperatively in relation to reported complications and severity
intra- and postoperatively. The women with a complication-free hysterectomy reported
an improved medical condition and satisfaction with the hysterectomy in 95 – 97% and
93 – 95%, respectively, but the prevalence decreased to 80 and 60%, respectively when
major complications had occurred.
The associations between complications and patient satisfaction reported one year
postoperatively are shown in [Table 4 ]. When adjusted for confounding factors, medical condition after one year was strongly
negatively associated with complications of all grades occurring after discharge from
hospital. Except for minor complications occurring intraoperatively, the reported
satisfaction with hysterectomy one year after surgery was strongly negatively associated
with all grades of severity of complications on all occasions. In particular, major
complications reported at the one-year inquiry were highly associated with dissatisfaction
with the result of surgery.
Table 4 Associations between complications and the dichotomized self-reported perception
of medical condition and satisfaction on various occasions until one year postoperatively.
Medical condition one year postoperatively:
Unchanged, worse or much worse
Opinion about the result of the surgery one year postoperatively:
Neither satisfied or dissatisfied
Factor
Crude OR and 95% CI
Adjusted OR and 95% CI*
Crude OR and 95% CI
Adjusted OR and 95% CI*
* Adjusted simultaneously for age, BMI, smoking habits, mode of hysterectomy, indication
of hysterectomy and having at least one remaining ovary postoperatively.
Intraoperative complications:
1.00 (reference)
1.00 (reference)
1.00 (reference)
1.00 (reference)
0.92 (0.53 – 1.62)
0.97 (0.54 – 1.76)
1.21 (0.90 – 1.62)
1.23 (0.90 – 1.68)
1.16 (0.47 – 2.87)
0.86 (0.27 – 2.76)
2.98 (1.94 – 4.58)
2.79 (1.74 – 4.46)
Complications during hospital stay:
1.00 (reference)
1.00 (reference)
1.00 (reference)
1.00 (reference)
1.55 (1.15 – 2.10)
1.53 (1.10 – 2.13)
1.62 (1.34 – 1.97)
1.65 (1.34 – 2.02)
1.51 (0.89 – 2.56)
1.60 (0.90 – 2.85)
3.25 (2.48 – 4.25)
3.37 (2.34 – 4.84)
Complication with eight weeks:
1.00 (reference)
1.00 (reference)
1.00 (reference)
1.00 (reference)
2.20 (1.80 – 2.69)
2.08 (1.66 – 2.62)
2.35 (2.05 – 2.68)
2.31 (2.00 – 2.67)
4.07 (2.92 – 5.68)
4.39 (3.04 – 6.34)
5.36 (4.33 – 6.64)
5.31 (4.20 – 6.71)
Complications between eight weeks and one year:
1.00 (reference)
1.00 (reference)
1.00 (reference)
1.00 (reference)
3.21 (2.56 – 4.01)
3.17 (2.47 – 4.08)
4.53 (3.93 – 5.22)
4.52 (3.87 – 5.28)
7.52 (5.27 – 10.72)
6.23 (4.06 – 9.55)
12.23 (9.70 – 15.42)
11.97 (9.29 – 15.42)
Unfavorable outcomes
[Table 5 ] shows various predictive factors for unfavorable outcome of surgery reported one
year postoperatively. In the adjusted models, the perceived medical condition was
significantly adversely associated with having no preoperative expectation of surgery
(aOR 4.85 [95% CI 2.80 – 8.40]), smoking (aOR 1.45 [95% CI 1.14 – 1.84]), having uterine
myoma (aOR 2.33 [95% CI 1.82 – 2.98]), or pain-related (aOR 3.29 [95% CI 2.57 – 4.22])
as indications for hysterectomy. Of the mode of hysterectomy only vaginal hysterectomy
was significantly positively associated with the medical condition reported at the
one-year inquiry (aOR 0.64 [95% CI 0.47 – 0.87]). Furthermore, vaginal and subtotal
abdominal hysterectomies were independent predictive factors for higher satisfaction
after surgery (aOR 0.61 [95% CI 0.51 – 0.71] and aOR 0.74 [95% CI 0.62 – 0.87], respectively).
Pain as indication of surgery was a strong risk factor for experienced dissatisfaction
(aOR 2.17 [95% CI 1.85 – 2.55]). Likewise, smoking and having no preoperative expectations
of surgery or believing that the only benefit of surgery would be alleviated of symptoms
and being without ovaries after the surgery were independently associated with dissatisfaction.
Intraoperative conversion of a minimally invasive procedure to laparotomy did not
seem to affect the reported medical condition or satisfaction with the surgery one
year after the operation.
Table 5 Risk factors for unfavorable outcome of the surgery concerning self-reported perception
of medical condition and satisfaction one year postoperatively. Results of logistic
regression analyses with dichotomized outcome measures.
Outcome measures
Medical condition: Unchanged, worse or much worse (reference: improved or much improved)
Opinion about result of surgery: Neither satisfied or dissatisfied (reference: satisfied
or very satisfied)
Factor
Crude OR and 95% CI
Adjusted OR and 95% CI*
Crude OR and 95% CI
Adjusted OR and 95% CI*
MIS – minimally invasive surgery.
* Adjusted simultaneously for age, BMI, smoking habits, mode of hysterectomy, indication
of hysterectomy and having at least one remaining ovary postoperatively.
Mode of hysterectomy:
1.00 (reference)
1.00 (reference)
1.00 (reference)
1.00 (reference)
0.85 (0.67 – 1.09)
0.97 (0.75 – 1.26)
0.68 (0.58 – 0.80)
0.74 (0.62 – 0.87)
1.13 (0.87 – 1.48)
1.10 (0.80 – 1.50)
1.02 (0.83 – 1.25)
0.87 (0.69 – 1.10)
0.67 (0.21 – 2.13)
0.65 (0.16 – 2.69)
0.62 (0.33 – 1.17)
0.56 (0.27 – 1.16)
0.54 (0.42 – 0.69)
0.64 (0.47 – 0.87)
0.55 (0.47 – 0.65)
0.61 (0.51 – 0.71)
Indication for hysterectomy:
1.00 (reference)
1.00 (reference)
1.00 (reference)
1.00 (reference)
2.47 (1.99 – 3.05)
2.33 (1.82 – 2.98)
1.34 (1.14 – 1.56)
1,22 (1.03 – 1.45)
3.15 (2.53 – 3.91)
3.29 (2.57 – 4.22)
2.38 (2.06 – 2.74)
2.17 (1.85 – 2.55)
2.30 (1.16 – 4.57)
2.18 (0.99 – 4.79)
1.65 (0.98 – 2.79)
1.23 (0.66 – 2.30)
Preoperative expectation of surgery:
1.00 (reference)
1.00 (reference)
1.00 (reference)
1.00 (reference)
1.23 (0.92 – 1.64)
1.08 (0.79 – 1.48)
1.37 (1.16 – 1.63)
1.23 (1.02 – 1.48)
4.49 (2.66 – 7.58)
4.85 (2.80 – 8.40)
2.68 (1.90 – 3.78)
2.74 (1.89 – 3.96)
Remaining at least one ovary postoperatively:
2.01 (1.52 – 2.65)
1.26 (0.90 – 1.76)
1.79 (1.47 – 2.18)
1.29 (1.02 – 1.62)
Conversion of surgery from MIS to abdominal:
1.33 (0.75 – 2.35)
1.65 (0.92 – 2.97)
1.24 (0.82 – 1.88)
1.17 (0.75 – 1.84)
Smoking:
1.42 (1.13 – 1.77)
1.45 (1.14 – 1.84)
1.31 (1.13 – 1.51)
1.23 (1.05 – 1.43)
ASA Class:
1.32 (0.62 – 2.85)
0.96 (0.35 – 2.65)
0.94 (0.51 – 1.74)
0.95 (0.48 – 1.88)
Age
1.00 (0.99 – 1.02)
1.01 (0.99 – 1.03)
0.99 (0.98 – 1.00)
0.99 (0.98 – 1.01)
BMI
1.00 (0.98 – 1.02)
1.01 (0.99 – 1.03)
0.99 (0.98 – 1.01)
1.00 (0.98 – 1.01)
Length of hospital stay (LOS)
The LOS for the entire study group was mean 2.3 days (1.9 days). Occurrence of complications
intraoperatively and postoperatively before discharge from hospital, and degree of
complications had statistically significant impact on LOS ([Fig. 3 a ] and [b ]). The LOS was predictive for occurrence and degree of complications reported after
discharge ([Fig. 3 c ] and [d ]). The post hoc tests revealed that there were highly statistically significant differences
in LOS (p < 0.001) between all three groups (complication-free, minor and major complications).
The adjusted LOS was mean 2.1 days (1.6 days) for those who had no reported complications
on any occasion. This was significantly lower than the mean 2.8 days (2.1 days) (p < 0.001)
for those who had a complication of any degree on at least one occasion.
Fig. 3 Length of hospital stay (LOS) in relation to occurrence of reported complications
after hysterectomy. a Intraoperative complications. b Complications after surgery during hospital stay. LOS was also adjusted for occurrence
of intraoperative complications. c Complications reported to have occurred between discharge and eight weeks postoperatively.
LOS was also adjusted for complications intraoperatively and during hospital stay.
d Complications reported to have occurred between the 8-weeks and 1-year inquiry. LOS
was also adjusted for complications intraoperatively, during hospital stay and at
the 8-weeks inquiry.
Discussion
The majority of women were satisfied with the result of the hysterectomy but there
was an association with decreased satisfaction when complications had occurred. Pelvic
pain as indication of surgery, no expectations preoperatively, and current smoking
were independent risk factors for adverse outcomes in patient satisfaction. Occurrence
of complications intra- and postoperatively before discharge from hospital was associated
with increasing LOS. Furthermore, LOS was predictive for occurrence and degree of
complications reported after discharge from hospital.
A strength of this research is the large study population, based on prospectively
collected data in the GynOp. More than 75% of all benign hysterectomies performed
in Sweden during the study period formed part of the register. Another strength is
that exclusion criteria were chosen to ensure that the indication of hysterectomy
was most likely of uterine origin and not related to other pelvic symptoms, diseases
or conditions that per se could have an impact on perceived satisfaction. However,
risk of selection bias and missing data in the register represent weaknesses of the
study. The interpretation of the results should be done with caution due to the inborn
risk of multiple testing problems in epidemiological studies. Due to the exploratory
nature of this study no statistical corrections of the p-values were done. A drawback
of the study and a limitation is the lack of an overall comprehensive validation of
the GynOp. However, several articles (> 50 in peer review reviewed journals) and more
doctoral dissertations emanate from the register [10 ] which indicate that the register is considered reliable, probably because of the
high internal coverage of all gynecological surgery in Sweden.
Prevalence and degree of intra- and postoperative complications in relation to mode
of surgery were in accordance with results of previous studies [5 ], [11 ]. Complications, especially major, were strongly associated with less contentment
with medical condition and satisfaction with surgery one year postoperatively. Moreover,
pain as indication of surgery, having no or low preoperative expectations of surgery,
and current smoking were above all significantly associated with adverse outcomes
concerning patient-reported satisfaction. Impact of different risk factors associated
with adverse outcomes in patient satisfaction following gynecological surgery have
rarely been described previously. Two studies have reported that minimally invasive
surgery seemed to be advantageous concerning patient satisfaction following hysterectomy
[7 ], [9 ]. Billfeldt et al. who also used data from GynOp, excluded women who had subtotal
hysterectomy in their study, although this surgical method is used in nearly 20% of
all benign hysterectomies in Sweden. In the present study, abdominal subtotal hysterectomy
and vaginal hysterectomy were independent factors associated with increased patient
satisfaction. The explanation of a higher satisfaction rate with subtotal hysterectomy
is not obvious. The choice of the surgical approach and technique are always discussed
with the patient. Perhaps these patients had a preference for subtotal hysterectomy
and therefore experienced a higher satisfaction due to this. On the other hand, subtotal
hysterectomy causes a higher risk of persistent vaginal bleeding postoperatively,
which could endanger the patient satisfaction [12 ]. Contrary to Billfeldt et al. who found a significantly higher satisfaction rate
after laparoscopic hysterectomy than after abdominal hysterectomy, this study revealed
no such advantage of the laparoscopic approach when adjusted for confounders such
as complications. Billfeldt et al. presented a multivariable analysis of satisfaction
rates, although not adjusted for complications that may have substantial impacts on
the outcomes. Even the American study by Pitter et al. did not adjust satisfaction
rates for occurrence of complications or other important confounders, although existence
of complications seems to be an important significant predictor of dissatisfaction.
Thus, none of these studies gave a generalizable answer to the question of satisfaction
after various modes of hysterectomy [7 ], [9 ].
Concerning association of pain as indication of hysterectomy with patient-reported
contentment with surgery, Grundström et al. previously reported that women with pelvic
pain and endometriosis were at a higher risk of being dissatisfied [5 ]. Brandsborg et al. stated that 32% of women reported chronic pain after hysterectomy
on benign indications. Risk factors for chronic pain were preoperative pelvic pain,
pain as main indication for surgery, and pain problems elsewhere preoperatively [13 ]. This would presumably also influence expected satisfaction with hysterectomy. The
negative association between having myoma as indication for the hysterectomy and the
perceived medical condition is difficult to explain. The main indication of surgery
registered in the GynOp was decided by the responsible gynecologist. Menstrual disorder
and pain are symptom diagnoses whereas myoma is a tentative patho-anatomical diagnosis
that usually is associated with symptoms such as menstrual disorder or mechanical
symptoms. The GynOp does not give norms for how to give priority to the indications.
Thus there might be a mixing of symptoms and anatomical abnormalities giving the ultimate
main indication. This could possibly influence the results for perceived medical condition.
The patientʼs preoperative expectation of surgery is probably also influenced by the
preoperative information given, although evidence is lacking. It differs greatly in
the beliefs and practices of healthcare professionals in the advice they give to patients
[14 ], [15 ]. Nevertheless, it seems likely that adequate and understandable patient-centered
information is important in order to achieve realistic preoperative expectations [16 ], [17 ]. Patients are more likely to be dissatisfied with result of surgery if they are
not satisfied with the preoperative information [18 ], [19 ]. The association between smoking and the negative outcomes in patient satisfaction
after surgery as seen in this study corresponds with findings in other studies [9 ], [20 ], [21 ]. The reasons are speculative, but psychosocial factors may be of importance.
It has previously been suggested that LOS is adversely associated with postoperative
complications [22 ], [23 ]. To the best of our knowledge no previous study has indicated that this association
seems to apply even to late appearing complications. Complications that occurred intra-
and postoperatively in this study prolonged hospital stay considerably. This is an
obvious drawback not only for the exposed women but also considering the deficiency
of institutional care and health economics. Interestingly, LOS was even associated
with the occurrence and degree of complications reported after discharge. When a major
complication occurred after discharge, the LOS was on average a half day longer than
for those who had a postoperative period without complications. Although a half day
may be considered as clinically insignificant the association seems to indicate that
something that happens during the hospital stay may predispose to complications in
the postoperative period even up to one year after the surgery. The reasons for this
remain speculative and merits further investigation. It therefore seems important
to avoid complications not only in the immediate perioperative course but also later
to achieve optimal quality of care.
Conclusions
This study showed that complications following hysterectomy were strongly associated
with less contentment with surgery and an increasing LOS. Prevention of both early
and late appearing complications seems to be of importance to optimize patient satisfaction.
Other risk factors for adverse outcomes were pain as indication of surgery, having
low or no expectations preoperatively, and current smoking. Patient-centered information
to ensure realistic preoperative expectations seems essential to gain optimal satisfaction
with surgery.