Despite well-documented evidence that vaginal hysterectomies are more advantageous in a majority of cases, physicians continue to use abdominal hysterectomies, says Emory University School of Medicine gynecologist S. Robert Kovac, MD. Although the vaginal approach promises fewer medical complications, substantially lower costs, and shorter recovery periods, abdominal hysterectomies are performed three times more often. An editorial by Dr. Kovac appearing in the June issue of Obstetrics and Gynecology, outlines the rationale and surgical approach for selecting the appropriate hysterectomy procedure for patients.
The more invasive abdominal hysterectomy is used more frequently because of a number of factors related to physician and patient knowledge, says Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery. Patients may not be offered options, and the surgeon's experience, training, comfort and preference may contribute to the predominance of the abdominal procedure.
The use of modern surgical instruments makes the transvaginal approach safe and more efficient, Dr. Kovac says. Modern instruments can enhance surgeon comfort level, reduce complications, expedite vaginal procedures and reduce costs. In fact, Dr. Kovac says, operative times for vaginal hysterectomies have been reduced to 10-20 minutes to complete the procedure.
Dr. Kovac's suggestions for increased use of transvaginal hysterectomies considered data from a large study of 4,595 hysterectomies performed at St. John's Mercy Medical Center in St. Louis, Missouri from 1988-1993. Results showed that using the vaginal approach rather than the abdominal or laparoscopic methods would have potentially saved almost $1.2 million per 1,000 hysterectomies performed at the institution. It would have also freed up 1,020 patient beds and reduced complications by approximately 20 percent.
"There are approximately 600,000 hysterectomies a year currently done in the United States, of which 70 percent, or 420,000, are abdominal," Dr. Kovac says. "At a potential savings of $1.2 million per 1,000 hysterectomies, the national savings could equal over a half billion dollars for using the vaginal method of hysterectomy."
Dr. Kovac also notes that vaginal hysterectomies have significant advantages for patients including less pain, decreased complications, faster recuperation, shorter hospital stay, faster return to normal activities, reduced hospital charges, and better quality-of-life outcomes.
Adopting evidence-based guidelines in medicine has shown to reduce inconsistencies and variations in health care. Evidence-based guidelines for hysterectomies have been tested in seven countries, including the United States. These guidelines were adopted by the Society of Pelvic Reconstructive Surgeons, which Dr. Kovac suggests gynecologist follow for a more objective approach to determine appropriate candidates for each type of hysterectomy. When surgeons follow the Society's guidelines, he says, an increase in the percentage of vaginal hysterectomies offered to women can be expected.
"In fact, the medical literature shows that the cost of a hysterectomy is two to three times higher than necessary because of the excessive number of abdominal and laparoscopic hysterectomies being performed without appropriate guidelines," Dr. Kovac writes.