Abstract
This PhD thesis is based on three original papers. The studies were conducted in 2015 – 2018 during my employment as a research fellow at the Department of Obstetrics and Gynecology at Herlev and Gentofte University Hospital, Denmark.
Pelvic organ prolapse (POP) affects millions of women worldwide. In apical prolapse there is a descent of the cervix, uterus, or vaginal vault in previously hysterectomised women. It is a benign condition but it is able to reduce the quality of life substantially. In many women surgical treatment is required to cure POP symptoms, and in Denmark the lifetime risk of POP surgery is
19% for women aged 80 years. The aim of POP surgery is to restore the normal vaginal anatomy and thereby reduce symptoms. Due to lack of evidence, the surgical strategy for repair of apical prolapse varies highly internationally, and vaginal hysterectomy (VH) has been the most common surgical treatment for
years. Together with the Manchester-Fothergill Procedure (MP) it is among the most frequently performed surgeries for apical prolapse in Denmark.
It has been forecasted that the annual costs associated with POP surgery will grow at twice the rate of population growth in the US and Europe during the next decades, amongst others due to the aging population. The overall aim of this thesis was to compare VH to the MP as a treatment of apical prolapse.
Moreover, we estimated the hospital costs related to the two procedures.
In study I we conducted a systematic review of the literature comparing VH to the MP as a treatment of apical prolapse. We found the existing literature to be very scarce and studies highly heterogenous, though in general in favour of the MP. More anatomic recurrences in the apical compartment were seen after VH, and the re-operation and conservative re-intervention rate were higher too. Furthermore, the operating time was longer and the postoperative blood loss larger for VH.
Study II and III were based on the same matched historical cohort including women with apical prolapse who had a VH or MP done in one of four public hospitals in the Capital region of Denmark in 2010-2014. All participants were followed from the date of surgery till recurrence, de novo POP or hysterectomy (for the MP-group only), alternatively to August 31st 2016, whichever came first. In total 295 participant pairs were matched on preoperative POP-Q stage
in the apical compartment and age. Follow-up ranged from 20 to 80 months. The study cohort was identified through the Danish Urogynecological Database (DugaBase). The Danish Hysterectomy and Hysteroscopy Database was used to identify and exclude patients registered with concurrent indications to VH. Data was obtained from the DugaBase, the Danish Anaesthesia Database, the Danish National Pathology Registry and Data Bank, and the corresponding electronic medical records.
Study II was a matched historical cohort study. We found recurrence or de novo POP to be significantly more frequent after VH both in any and in each compartment individually. In any compartment recurrence or de novo POP was seen in 18.3% after VH compared to 7.8% after MP (P=0.0002) (HR=2.5, 95% CI: 1.3-4.8). The relative risk of recurrence in the apical compartment specifically was 10 after VH (95% CI: 1.3-78.1), as recurrence occurred in 5.1% after VH and 0.3% after the MP (P=0.0004). Perioperative complications were also more frequent after VH (2.7%) than the MP (0%) (P=0.007), and so was postoperative intra-abdominal bleeding (2.0% vs. 0%, P=0.03). A small lymfocytic lymphoma was found in the removed uterus in one patient (0.3%) from the VH-group, and during follow-up one patient (0.3%) from the MP-group was diagnosed with a
stadium IA endometrial adenocarcinoma.
In study III we conducted an activity-based costing analysis in which we found that the total average costs at 20 months follow-up were 3,514 € for a VH compared to 2,318 € for a MP, corresponding to a difference of 1,196 € (95% CI: 927-1465 €) (P0.0001). When the primary surgery only was analyzed, the cost difference was 898 € (95% CI: 818-982) (P0.0001). The cost difference seemed to be reasonably constant in the long run when looking at the entire follow-up of 80 months. For VH the time in the operating theatre, duration of surgery, stay in PACU, and hospital stay were all significantly longer than for the MP.
In conclusion, we found that the MP is more durable than VH for all ompartments. It is also associated with fewer perioperative complications than VH, and no cases of intra-abdominal bleeding were seen after the MP. Furthermore, the incidence of postoperative uterine malignancy was very low. VH is significantly more expensive than the MP in treatment of apical prolapse,
thus considerable economic resources can be saved if the MP is chosen over VH in the treatment of apical prolapse. The outcomes of this thesis suggest that the MP should be preferred to VH with uterosacral ligament suspension in apical prolapse repair.
Pelvic organ prolapse (POP) affects millions of women worldwide. In apical prolapse there is a descent of the cervix, uterus, or vaginal vault in previously hysterectomised women. It is a benign condition but it is able to reduce the quality of life substantially. In many women surgical treatment is required to cure POP symptoms, and in Denmark the lifetime risk of POP surgery is
19% for women aged 80 years. The aim of POP surgery is to restore the normal vaginal anatomy and thereby reduce symptoms. Due to lack of evidence, the surgical strategy for repair of apical prolapse varies highly internationally, and vaginal hysterectomy (VH) has been the most common surgical treatment for
years. Together with the Manchester-Fothergill Procedure (MP) it is among the most frequently performed surgeries for apical prolapse in Denmark.
It has been forecasted that the annual costs associated with POP surgery will grow at twice the rate of population growth in the US and Europe during the next decades, amongst others due to the aging population. The overall aim of this thesis was to compare VH to the MP as a treatment of apical prolapse.
Moreover, we estimated the hospital costs related to the two procedures.
In study I we conducted a systematic review of the literature comparing VH to the MP as a treatment of apical prolapse. We found the existing literature to be very scarce and studies highly heterogenous, though in general in favour of the MP. More anatomic recurrences in the apical compartment were seen after VH, and the re-operation and conservative re-intervention rate were higher too. Furthermore, the operating time was longer and the postoperative blood loss larger for VH.
Study II and III were based on the same matched historical cohort including women with apical prolapse who had a VH or MP done in one of four public hospitals in the Capital region of Denmark in 2010-2014. All participants were followed from the date of surgery till recurrence, de novo POP or hysterectomy (for the MP-group only), alternatively to August 31st 2016, whichever came first. In total 295 participant pairs were matched on preoperative POP-Q stage
in the apical compartment and age. Follow-up ranged from 20 to 80 months. The study cohort was identified through the Danish Urogynecological Database (DugaBase). The Danish Hysterectomy and Hysteroscopy Database was used to identify and exclude patients registered with concurrent indications to VH. Data was obtained from the DugaBase, the Danish Anaesthesia Database, the Danish National Pathology Registry and Data Bank, and the corresponding electronic medical records.
Study II was a matched historical cohort study. We found recurrence or de novo POP to be significantly more frequent after VH both in any and in each compartment individually. In any compartment recurrence or de novo POP was seen in 18.3% after VH compared to 7.8% after MP (P=0.0002) (HR=2.5, 95% CI: 1.3-4.8). The relative risk of recurrence in the apical compartment specifically was 10 after VH (95% CI: 1.3-78.1), as recurrence occurred in 5.1% after VH and 0.3% after the MP (P=0.0004). Perioperative complications were also more frequent after VH (2.7%) than the MP (0%) (P=0.007), and so was postoperative intra-abdominal bleeding (2.0% vs. 0%, P=0.03). A small lymfocytic lymphoma was found in the removed uterus in one patient (0.3%) from the VH-group, and during follow-up one patient (0.3%) from the MP-group was diagnosed with a
stadium IA endometrial adenocarcinoma.
In study III we conducted an activity-based costing analysis in which we found that the total average costs at 20 months follow-up were 3,514 € for a VH compared to 2,318 € for a MP, corresponding to a difference of 1,196 € (95% CI: 927-1465 €) (P0.0001). When the primary surgery only was analyzed, the cost difference was 898 € (95% CI: 818-982) (P0.0001). The cost difference seemed to be reasonably constant in the long run when looking at the entire follow-up of 80 months. For VH the time in the operating theatre, duration of surgery, stay in PACU, and hospital stay were all significantly longer than for the MP.
In conclusion, we found that the MP is more durable than VH for all ompartments. It is also associated with fewer perioperative complications than VH, and no cases of intra-abdominal bleeding were seen after the MP. Furthermore, the incidence of postoperative uterine malignancy was very low. VH is significantly more expensive than the MP in treatment of apical prolapse,
thus considerable economic resources can be saved if the MP is chosen over VH in the treatment of apical prolapse. The outcomes of this thesis suggest that the MP should be preferred to VH with uterosacral ligament suspension in apical prolapse repair.
| Originalsprog | Engelsk |
|---|
| Antal sider | 108 |
|---|---|
| Status | Udgivet - 2018 |