Removing part of the uterus using a keyhole surgery technique is a more effective way of treating heavy menstrual bleeding than the current most common operation, according to new research led by the University of Aberdeen.
The research, funded by the National Institute for Health Research is published in The Lancet today.
In the mid-1990s, Aberdeen researchers were among the first to show that endometrial ablation (destroying the lining of the womb) was an effective and less invasive alternative to traditional hysterectomy, which involves full removal of the uterus and the cervix.
Since then, hysterectomy has been considered a last resort for combating heavy menstrual bleeding, which affects 25% of women in the UK.
However, in recent years, a number of trials comparing traditional hysterectomy and endometrial ablation showed that full removal of the uterus provided greater relief from symptoms but led to more complications.
Now, in a new study published today in The Lancet, Aberdeen researchers led by Professor Kevin Cooper, have shown that a modified hysterectomy technique where only the body of the uterus is removed (leaving the neck of the womb – the cervix – behind) using keyhole surgery, is as safe as endometrial ablation but much more effective.
Researchers carried out a randomized trial on 660 women with heavy menstrual bleeding, across the UK.
Half had endometrial ablation while the other half had the new technique – laparoscopic supra-cervical hysterectomy (LASH).
Fifteen months after their surgery, the women treated using LASH were more satisfied with their treatment, but complication rates were similar in both groups.
Jane Smith, 47, from Kincorth in Aberdeenshire, had the LASH procedure in January 2018 after suffering from heavy and painful periods for many years.
“I had tried medication and the Mirena coil, without success. I had an endometrial ablation two years ago but unfortunately that also failed.
“Professor Cooper mentioned the LASH procedure and explained what was involved and I agreed to be listed for the procedure.
“The operation went very well and I was home by 8pm the same day. For a week afterwards I was sore and uncomfortable but this was attributed to the gas used during the operation.
I was able to return to work after four weeks.
The operation has been a total success and I have had no problems since the procedure. I am very grateful to Professor Cooper for suggesting the procedure to me.”
Professor Kevin Cooper from the University of Aberdeen, who is also a consultant gynecologist with NHS Grampian, said:
“This study shows that LASH offers a more effective option than endometrial ablation, without any increased risks. Most women having this procedure get home within 24 hours and there are no restrictive rules for recovery, unlike traditional hysterectomy. Laparoscopic supracervical hysterectomy offers women another effective surgical choice for this common medical condition.”
Professor Siladitya Bhattacharya, a co-author in this study, added:
“This study is the latest in a series of trials led by Aberdeen over the past 25 years, which have helped to make surgery for heavy menstrual bleeding safer and more effective.”
Aim
By evaluating operative outcomes relative to cost, we compared the value of minimally invasive hysterectomy approaches, including a technique discussed less often in the literature, laparoscopic retroperitoneal hysterectomy (LRH), which incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin.
Methods
Retrospective chart review of all women (N = 2689) aged greater than or equal to 18 years who underwent hysterectomy for benign conditions from 2011 to 2013 at a high‐volume hospital in Maryland, USA.
Procedures included: laparoscopic supracervical hysterectomy, robotic‐assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy, laparoscopic‐assisted vaginal hysterectomy, total vaginal hysterectomy (TVH), and LRH.
Results
Total vaginal hysterectomy had the highest intraoperative complication rate (9.6%; P < 0.0001) but the lowest postoperative complication rate (1.8%; P < 0.0001). Robotics had the highest postoperative complication rate (11.4%; P < 0.0001).
LRH had the shortest operative time (71.2 min; P < 0.0001) and the lowest intraoperative complication rates (2.1%; P < 0.0001). LRH and TVH were the least costly (averaging $4061 and $6416, respectively), while RALH was the most costly ($9354).
Taking both operative outcomes and cost into account, LRH, TVH and laparoscopic‐assisted vaginal hysterectomy yielded the highest value scores; total laparoscopic hysterectomy, RALH, and laparoscopic supracervical hysterectomy yielded the lowest.
Conclusion
Understanding the value of surgical interventions requires an evaluation of both operative outcomes and direct hospital costs. Using a quality‐cost framework, the LRH approach as performed by high‐volume laparoscopic specialists emerged as having the highest calculated value.
Introduction
The soaring costs of health care in the United States combined with the recent uncertainty of the Affordable Care Act have intensified the focus on value‐based healthcare delivery. Healthcare spending has been growing as a share of the national income for decades – from 10% in 1985 to 17% in 2010 – and it is projected to keep rising to almost 25% in 2037.1 Healthcare economists estimate that 40–50% of annual cost increases can be traced to new technologies, such as the da Vinci robot.2
There is ongoing debate regarding whether the benefits are worth the costs of this technology.3 To quote Yong et al.:
The rising healthcare costs in the United States in the face of global economic turmoil underscore the necessity for a health system that identifies and eliminates low‐value services, minimizes inappropriate use of medical services, and responds to the explosion of costly new technologies, thus positioning value as a key cornerstone to improving the quality of care delivered in this country.4
A corrective shift toward a value‐based model is needed to move the healthcare system in the direction of greater sustainability, offering benefits to the provider, payor and the patient.5
While the need to use both cost and quality measures to assess the value of physician practices, hospitals and health plans is well established in the literature,4, 6 there is currently no consensus or practical set of guidelines on how to compare the value of surgical modalities.
As surgical care accounts for more than 40% of spending for inpatient care,7 operationalizing and identifying the value of varying surgical routes is critical for healthcare stakeholders seeking to control costs without sacrificing quality.
By developing a quality‐cost framework, our study attempted to assess and compare the value of minimally invasive hysterectomy procedures to an approach less commonly performed: laparoscopic retroperitoneal hysterectomy (LRH).
More information: Kevin Cooper et al. Laparoscopic supracervical hysterectomy versus endometrial ablation for women with heavy menstrual bleeding (HEALTH): a parallel-group, open-label, randomised controlled trial, The Lancet (2019). DOI: 10.1016/S0140-6736(19)31790-8
Journal information: The Lancet
Provided by University of Aberdeen
