Female sterilization III.
Vaginal
RUSSELL BRUCE Ann
K. A.
Arbor,
hysterectomy
LAROS,
WORK,
M.D.,
JR., JR.,
M.Sc.
M.D.
Michigan
One hundred and eleven cases of vaginal hysterectomy for sterilization, performed over a period of five and a half years, were analyzed and compared with alternative methods of female sterilization. The mean operating time for vaginal hysterectomy was 98 minutes, and the mean length of hospitalization was 9.5 days. Immediate morbidity of one sort or another occurred in 89 cases (90.0 per cent), while the incidence of standard morbidity was 40.9 per cent (35 cases). These data compare most unfavorably with findings for interval tubal ligation by either the vaginal or laparoscopic approach. Our data indicate that vaginal hysterectomy for sterilization should be used only in selected patients where there is a clear indication for hysterectomy above and beyond the desire for sterilization.
T H E R o L E o F vaginal hysterectomy as a method of female sterilization has been a matter of controversy and debate. There are those who feel this procedure is the only logical method of female sterilizationr, ? and those”-j who decry its use because of the attendant high morbidity and prolonged hospitalization. We wish to report our experience with vaginal hysterectomy for sterilization and to compare it with other methods of female sterilization performed in our institution over an identical time period. Material
and
of vaginal hysterectomy were recorded. Because it frequently was not possible to determine the real indication for vaginal hysterectomy from the log, all such operations performed on women between the ages of 15 and 45 years with preoperative diagnoses other than gynecology malignancy were reviewed. If the patient initially presented requesting sterilization, the case was included, even though additional historical factors and/or physical findings provided additional indications for hysterectomy. A data sheet designed for computer analysis was used, and each record was reviewed for 56 variables (Table I). Each chart was abstracted two or more years after the date of the procedure. Appropriate subgroupings were made for each categorical variable. The variables analyzed fell into one of 6 major categories: vital statistics, indication (s) for sterilization, past history, operative procedure, morbidity, and follow-up period. Most of the variables listed in Table I are self-explanatory. The days in the hospital (Variable 4) were obtained by subtracting the date of admission from the date of discharge. The year of operation was subdivided into quarters (Variable 12) to see if the progression of house officer training within a given year had any effect on surgical results. The indications for sterilization (Variables 15 to 34) were further divided into indicated (Variables 15 to 30 and 33 and 34) and elective or voluntary
methods
The study period was from July 1, 1965, through December 3 1, 1970 (five and a half years). During those years, the Department of Obstetrics and Gynecology at the University of Michigan included services at both the University Hospital in Ann Arbor and the Wayne County General Hospital (WCGH) in Eloise. The logs of the operating suites were reviewed by the authors, and all cases From the Department Gynecology, University Received Accepted
for publication October
of Obstetrics of Michigan, September
and Ann
Arbor.
19, 1974.
4, 1974.
Reprint requests: Dr. Russell K. Laros, Jr., Department of Obstetrics and Gynecology, University of California, San Francisco, School of Medicine, San Francisco, California 94143. 693
Table I. Variables _~____._
No. - Variable Vital statistics 1 ‘1 ‘I i 5 6 7 8 9 10 11 I2 13 14
Table II. Patient
analyzed
--- ...-- --
population
.~
I
Variable Characteristic Hospital Race Religion Days in hospital Age Gravidity Parity Abortions Weight Marital status Year of operation Quarter of year Months since end of last pregnancy Day of cycle operation performed
Indications for sterilization 15 Cesarean sections 16 Psychosis 17 Neurosis 18 Heart disease 19 Hypertension 20 Pulmonary disease Diabetes 21 Collagen disease 22 Renal disease 23 Neurologic disease 24 25 Thromboembolism 26 Eugenic 27 Mental retardation 28 Rh sensitization 29 Hemoglobinopathy 30 Malignancy Socioeconomic 31 Multiparity 32 Other 33 Unknown 34 Past history Contraception 35 Gynecologic history 36 Surgical history 37 Operative procedure 38 Anesthesia Anesthesia time 39 Operating time 40 Surgeon (level of training) 41 Surgical method 42 Associated operations 43 Estimated blood loss 44 Preoperative hematocrit 45 Operative complication 46 Treatment of complication 47 Morbidity 48 Immediate morbidity 49 Cause of febrile morbidity 50 Cause of nonfebrile morbidity Cultures 51 52 Tubal histology Treatment of morbidity 53 Follow-up Length in years 54 Delayed complications 55 Further gynecologic operations 56
Mean
Analytical variables Age (years ) Gravidity Abortions Weight (pounds) Hematocrit (% ) Categorical variables (%) Hospital University WCGH Race White Black Marital status Married Single Widowed Divorced Separated
/
32.4 5.7 0.96 144 40.8
Stundard deviation
Range 21-44 o-13 O-8 86-250 30-51
5. i 2.7 1.5 33 :;.7
31.5 68.5 81.8 18.2 82.0 3.6 2.7 5.4 6.3
(Variables 31, 32) categories. The various medical indications were accepted only if the patient had received treatment for that illness, i.e., hypertension was acceptable only if the patient had received antihypertensive therapy. Multiparity included those patients whose parity was 4 or greater. Any patient might have had more than one indication for sterilization. The anesthesia time (Variable 39) was obtained directly from the anesthesia record, and the operating time (Variable 40) was obtained from the record of operation (the starting and finishing times were recorded by the operating room nurse). The surgeon (Variable 41) was subgrouped according to the level of training of the actual operator, i.e., student, house officer I, II, etc., and staff physician. Immediate morbidity (Variable 48) was subdivided into standard morbidity, one-day fever, nonfebrile morbidity, and any combination of the above. Standard morbidity was defined as a temperature of 38’ C. (100.4O F.) or greater on any two of the first 10 postoperative days exclusive of the day of operation. A one-day fever was considered as a temperature elevation to 37.8’ C. (100.0’ F.) or greater on any single day. Any patient given prophylactic antibiotics was excluded from the study. Frequency Lrariable,
distributions and
respect
to
might
predispose
each
were subgroup
morbidity to
constructed
for
each
was
analyzed
with
so as to identify
factors
which
morbidity.
Prepared
public
Volume Number
I?? 6
Table
III.
Female
Gynecologic
Table
history 1
History Abnormal uterine bleeding Salpingitis Stress urinary incontinence Pelvic relaxation Cervical stenosis Pelvic pain Dysmenorrhea Dyspareunia Other
Table
IV. Previous
pelvic
26.1 2.7 8.1 4.5 0.9 1.8 1.8 1.8 8.2
operations
Procedure
/
No. 9 4 2 1 2 19 20
/ % of total
8.2 3.6 1.8 0.9 1.8 17.1 18.0
Results During the period studied (five and a half years), 1,757 female sterilizations were performed, of which 111 (6.3 per cent) were accomplished by vaginal hysterectomy. Table II details the variables descriptive of the patient population. The findings show that the usual patient was a married, white, multiparous woman in the mid-30’s. In recent years there has been increasing enthusiasm for vaginal hysterectomy as a method of sterilization at our institution. This is documented by the finding that 21.6 per cent of cases were performed in the first 2vz years of the study as compared with 78.4 per cent of the cases in the latter three years, 56.8 per cent of cases being done in the year 1970 alone. However, a similar exponential rise in the frequency of other female sterilizing operations also has been noted in our institution.
695
1-
Febrile Onestanday dard + fever + TlO?l-
Cause
Nonfebrile
febrile
standard
day fever
WlOT-
7?lO7-
bidity
bidity
bidity
17 16 4 0 0 0 2 6 45
14 1 0 2 1 3 1 15 37
1 0 1 0 0 0 0 0 T
1 0 1 0 0 0 0 0 -2
1 0 0 0 0 0 1 0 2
Urinary tract infection Pelvic cellulitis Pelvic abscess Pulmonary Thrombophlebitis Bleeding Other Unknown Total
Table
loll-
One-
VI. Modalities
febrile
of treatment
Treatment
computer programs of the Statistical Research Laboratory of the University of Michigan were used for all statistical analyses. Categorical variables were compared with the use of the chi-square analysis with the Yates correction. Comparisons between analytical variables were analyzed with Student’s t test or a one-way analysis of variance, as appropriate. Probability values were calculated from a two-tailed table, and only values of P < 0.05 were considered significant.
III
morbidity
% of total
No. 29 3 9 5 1 2 2 2 9
Gastrointestinal with infection Gastrointestinal without infection Cesarean section Tubal Ovarian Dilatation and curettage Other or combinations
V. Immediate
sterilization.
Antibiotics Antibiotics + drainage Antibiotics + adnexal procedure Transfusion + operation to control cuff bleeding Transfusion + vaginal pack Total
I
No. 44 5 5 1 1 56
Although most procedures (73.4 per cent) were done six months or more after a patient’s most recent delivery or abortion, 10.8 per cent were done in the puerperium. This latter group includes three therapeutic abortions with sterilization accomplished by vaginal hysterectomy. The indication for sterilization was socioeconomic and/or multiparity in 68.5 per cent; medical, in 20.7 per cent; psychiatric, in 4.5 per cent; genetic, in 4.5 per cent; and previous cesarean section, in 1.8 per cent of cases. Twenty per cent of the patients were using no form of contraception; 57 per cent, oral contraceptives; 14 per cent, an intrauterine contraceptive device; and 9 per cent, foam or a mechanical contraceptive. Tables III and IV summarize the previous gynecologic history and previous surgical history of the study group. Forty-five per cent of the patients had no significant past gynecologic history. The commonest abnormalities noted were abnormal uterine bleeding and pelvic relaxation. Fifty-one per cent of the patients had previous pelvic operations. The com-
rnonest procedurr wits dilatation and curettage alone or in combination with another operation. ‘I’he mean anesthesia time was 128 minutes (range == 70 to 260; standard deviation [S.D.] = 39), while the mean operating time was 98 minutes (range =p 35 to 233; SD. = 39). Most patients received general anesthesia (97.3 per cent). The operating surgeon was most commonly a senior individual, 87.4 per cent being third- or fourth-year house officers and 9 per cent being faculty members. Sixty-nine patients (62.2 per cent) had only vaginal hysterectomy performed, while 35 (31.5 per cent) had vaginal plastic procedures, 3 (2.7 per cent) had ovarian procedures, and 4 (3.6 per cent) had other additional operative procedures. The performance of associated surgery had a significant effect on several variables. The anesthesia time was increased by 29.4 minutes (t = 3.8; P = 0.0001). Vaginal plastic procedures were performed on more white than black patients (33.3 versus 15 per cent) (chi square = 2.6; P, not significant [N.S.]) , and estimated blood loss (EEL) greater than 250 ml. was significantly more common (chi square = 8.2: P = 0.0033) if associated surgical procedures were performed. The question of morbidity was examined in great detail (Table V) . Only 22 patients (20.0 per cent) escaped morbidity, while 35 (40.9 per cent) had standard morbidity, 37 (33.6 per cent) had one-day fevers, and two each (1.8 per cent) had nonfebrile morbidity, standard morbidity plus nonfebrile morbidity, or one-day fever plus nonfebrile morbidity. As an explanation for morbidity, urinary tract infection was diagnosed 34 times; pelvic cellulitis, 17 times; pelvic abscess, 6 times; cause of morbidity unknown, 21 times; and some other complication, 10 times. Most morbidity responded satisfactorily to antibiotics or some other medical modality of management (Table VI). However, additional surgical procedures were necessary in 11 cases ( 10 per cent of total series). Vaginal or abdominal drainage was utilized in addition to antibiotics in five cases; five patients required bilateral salpingo-oophorectomy in order to control postoperative pelvic infection, and one patient required resuturing of the vaginal cuff. Immediate morbidity was compared to all other variables in an attempt to identify significant correlations which might aid in anticipating morbidity. Immediate morbidity was more common at Wayne County General Hospital than at the University Hospital (chi square = 7.2; P = 0.027). Morbidity
was significantly higher if vaginal hysterectoriiy was performed during the puerperium. All 21 patients operated upon during the puerperium had febrile morbidity (chi square = 6.2; P = 0.0065). Morbidity did not correlate with the time in the menstrual cycle at which the operation was donr, anesthesia or operating time, the performance of associated procedures, the level of training of the surgeon, the quarter of the year in which operation was performed, or any other variables analyzed. Although there was a trend suggesting that less morbidity had occurred in recent years (50 per cent morbidity in the first two and a half years versus 38.4 per cent in the most recent three years), the difference was not significant at the 5 per cent level. The average length of hospitalization for all patients was 9.5 days with the shortest stay being four days and the longest 31 days. The length of stay was significantly affected by whether or not a vaginal plastic procedure was performed. This associated procedure added 3.6 days to the hospital stay (t = 3.63; P = 0.0005). The occurrence of morbidity also significantly lengthened the hospital stay. Febrile morbidity added 3.0 days to the stay and nonfebrile (chi square = 2.65; P = 0.0095)) morbidity added 8 days to the hospital stay (chi square = 2.40; P = 0.0184). The estimated blood loss showed a positive correlation with performance of associated surgical procedures, anesthesia time, operating time, and the relationship of the procedure to the most recent pregnancy (P = 0.0087, 0.0016, 0.0001, and 0.0379, respectively). Again there was no correlation with the level of training of the surgeon or with the cycle day on which the procedure was performed. Operative complications were uncommon. There were two bowel injuries, one bladder injury, and 18 instances of blood loss exceeding 500 ml. The bladder injury and bowel injuries (one small bowel and one large bowel below the peritoneaf reflection) were all repaired vaginally. One third of the 18 whom excessive blood loss occurred patients in required transfusion. Seventy-four per cent of the patients were seen on one or more occasions at some time later than six weeks after operation. Only 9 (11.1 per cent) patients have had additional problems. There were three instances of repeated urinary tract infection, three instances of emotional problems, one bartholin’s gland cyst, one ovarian cyst, and one vaginal mass. These latter two problems required a major
Volume Number
122 G
Female
and a minor correction.
additional
operative
procedure
for
Comment
An ideal method of female sterilization is one with a short operating time, short hospital stay, low blood loss and transfusion requirement, low rates of morbidity and operative complications, and a minimum of late sequelae. During this same period of five and a half years, 820 other interval female sterilizations were performed by other methods. When compared to these alternative procedures, vaginal hysterectomy does not seem ideal. The average operating time for laparoscopic tubal ligation was 33.1 minutes; for colpotomy tubal ligation, 43.3 minutes; for abdominal tubal ligation, 64.7 minutes; and for abdominal hysterectomy, 128 minutes. Vaginal hysterectomy required a significantly longer (P = 0.001) operating time than any of these except abdominal hysterectomy. The average length of hospital stay for laparoscopic tubal ligation was 3.4 days and that for colpotomy tubal ligation was 4.3 days, which is significantly shorter (P = 0.001) than the 9.5 days required for vaginal hysterectomy. The estimated blood loss is also significantly less in those patients undergoing interval laparoscopic tubal ligation and colpotomy tubal ligation (P < 0.001). Only 20.4 per cent of our patients undergoing vaginal hysterectomy escaped morbidity, and 42.7 per cent experienced standard morbidity. This compares with a standard morbidity rate of 1.5 per cent for laparoscopic tubal ligation, 5.7 per cent for colpotomy tubal ligation, 20.7 per cent for abdominal tubal ligation, and 45.2 per cent for abdominal hysterectomy. All of these rates except that for abdominal hysterectomy differ significantly from those for vaginal hysterectomy.
sterilization.
Ill
697
The very high incidence of febrile morbidity associated with vaginal hysterectomy stimulated Ledger and associates” to examine the role of prophylactic antibiotic therapy for such cases at our institution. They found that prophylactic cephaloridine (three intramuscular doses of 1 Gm. eachon call to the operating room, on return to the floor. and at bedtime the evening of operation) reduced standard morbidity from 46 to 24 per cent (P < 0.025). We had hoped to be able to identify a particularly high-risk group of women so that antibiotic prophylaxis could be reserved for them. Unfortunately, the only factors identified were the hospital and the length of time since the last pregnancy. This is in sharp contrast to our findings with tubal ligation via colpotomy where operating time and excessive blood loss correlated significantly with postoperative morbidity.’ Because of the above findings, for the past several years, it has been our practice to administer prophylactic antibiotics to almost all premenopausal women undergoing vaginal hysterectomy in the hope of reducing standard morbidity to the range of 20 to 25 per cent. Thus, in summary, our experience indicates that vaginal hysterectomy is not an ideal method of female sterilization. It is attended by significant morbidity, prolonged hospitalization, a long operating time, and significant blood loss. We feel that it should be used only in highly selected patients where there is a clear indication for hysterectomy above and beyond the desire for sterilization. We wish to acknowledge the able assistance and guidance of Esther Schaeffer, Statistical Research Laboratory, University of Michigan, Ann Arbor, Michigan.
REFERENCES
1. Atkinson, 2.
S. J., and Chappell, 39: 759, 1972. Van Nagell, J. R., and Raddick, GYNECOL.
3.
Hibbard, 1972.
S. B.: Ohstet. J. W.: AM
Gynecol. J. OBSTET.
111: 703, 1971. L. T.:
AM.
4. Roach, C. .J., Krolak,
J. OBSTET.
GYNECOL.
112:
5. 6.
1076. 7.
J. D., Powell,
J. L., Llorens,
A. S., and Deuhler, K. F.: AM. J. OBSTET. GYNECOL. 114: 670, 1972. Schulman, H.: Obstet. Gynecol. 40: 738, 1972. Ledger, W. J., Sweet, R. L., and Headington, J. T.: AM. 1. OBSTET. GYNECOL. 115: 766. 1973. Rowe: R. E., Laros, R. K., and WGk, B. A.: AM. J. OBSTET. GYNECOL. 112: 1031, 1972.
Vaginal
RUSSELL BRUCE Ann
K. A.
Arbor,
hysterectomy
LAROS,
WORK,
M.D.,
JR., JR.,
M.Sc.
M.D.
Michigan
One hundred and eleven cases of vaginal hysterectomy for sterilization, performed over a period of five and a half years, were analyzed and compared with alternative methods of female sterilization. The mean operating time for vaginal hysterectomy was 98 minutes, and the mean length of hospitalization was 9.5 days. Immediate morbidity of one sort or another occurred in 89 cases (90.0 per cent), while the incidence of standard morbidity was 40.9 per cent (35 cases). These data compare most unfavorably with findings for interval tubal ligation by either the vaginal or laparoscopic approach. Our data indicate that vaginal hysterectomy for sterilization should be used only in selected patients where there is a clear indication for hysterectomy above and beyond the desire for sterilization.
T H E R o L E o F vaginal hysterectomy as a method of female sterilization has been a matter of controversy and debate. There are those who feel this procedure is the only logical method of female sterilizationr, ? and those”-j who decry its use because of the attendant high morbidity and prolonged hospitalization. We wish to report our experience with vaginal hysterectomy for sterilization and to compare it with other methods of female sterilization performed in our institution over an identical time period. Material
and
of vaginal hysterectomy were recorded. Because it frequently was not possible to determine the real indication for vaginal hysterectomy from the log, all such operations performed on women between the ages of 15 and 45 years with preoperative diagnoses other than gynecology malignancy were reviewed. If the patient initially presented requesting sterilization, the case was included, even though additional historical factors and/or physical findings provided additional indications for hysterectomy. A data sheet designed for computer analysis was used, and each record was reviewed for 56 variables (Table I). Each chart was abstracted two or more years after the date of the procedure. Appropriate subgroupings were made for each categorical variable. The variables analyzed fell into one of 6 major categories: vital statistics, indication (s) for sterilization, past history, operative procedure, morbidity, and follow-up period. Most of the variables listed in Table I are self-explanatory. The days in the hospital (Variable 4) were obtained by subtracting the date of admission from the date of discharge. The year of operation was subdivided into quarters (Variable 12) to see if the progression of house officer training within a given year had any effect on surgical results. The indications for sterilization (Variables 15 to 34) were further divided into indicated (Variables 15 to 30 and 33 and 34) and elective or voluntary
methods
The study period was from July 1, 1965, through December 3 1, 1970 (five and a half years). During those years, the Department of Obstetrics and Gynecology at the University of Michigan included services at both the University Hospital in Ann Arbor and the Wayne County General Hospital (WCGH) in Eloise. The logs of the operating suites were reviewed by the authors, and all cases From the Department Gynecology, University Received Accepted
for publication October
of Obstetrics of Michigan, September
and Ann
Arbor.
19, 1974.
4, 1974.
Reprint requests: Dr. Russell K. Laros, Jr., Department of Obstetrics and Gynecology, University of California, San Francisco, School of Medicine, San Francisco, California 94143. 693
Table I. Variables _~____._
No. - Variable Vital statistics 1 ‘1 ‘I i 5 6 7 8 9 10 11 I2 13 14
Table II. Patient
analyzed
--- ...-- --
population
.~
I
Variable Characteristic Hospital Race Religion Days in hospital Age Gravidity Parity Abortions Weight Marital status Year of operation Quarter of year Months since end of last pregnancy Day of cycle operation performed
Indications for sterilization 15 Cesarean sections 16 Psychosis 17 Neurosis 18 Heart disease 19 Hypertension 20 Pulmonary disease Diabetes 21 Collagen disease 22 Renal disease 23 Neurologic disease 24 25 Thromboembolism 26 Eugenic 27 Mental retardation 28 Rh sensitization 29 Hemoglobinopathy 30 Malignancy Socioeconomic 31 Multiparity 32 Other 33 Unknown 34 Past history Contraception 35 Gynecologic history 36 Surgical history 37 Operative procedure 38 Anesthesia Anesthesia time 39 Operating time 40 Surgeon (level of training) 41 Surgical method 42 Associated operations 43 Estimated blood loss 44 Preoperative hematocrit 45 Operative complication 46 Treatment of complication 47 Morbidity 48 Immediate morbidity 49 Cause of febrile morbidity 50 Cause of nonfebrile morbidity Cultures 51 52 Tubal histology Treatment of morbidity 53 Follow-up Length in years 54 Delayed complications 55 Further gynecologic operations 56
Mean
Analytical variables Age (years ) Gravidity Abortions Weight (pounds) Hematocrit (% ) Categorical variables (%) Hospital University WCGH Race White Black Marital status Married Single Widowed Divorced Separated
/
32.4 5.7 0.96 144 40.8
Stundard deviation
Range 21-44 o-13 O-8 86-250 30-51
5. i 2.7 1.5 33 :;.7
31.5 68.5 81.8 18.2 82.0 3.6 2.7 5.4 6.3
(Variables 31, 32) categories. The various medical indications were accepted only if the patient had received treatment for that illness, i.e., hypertension was acceptable only if the patient had received antihypertensive therapy. Multiparity included those patients whose parity was 4 or greater. Any patient might have had more than one indication for sterilization. The anesthesia time (Variable 39) was obtained directly from the anesthesia record, and the operating time (Variable 40) was obtained from the record of operation (the starting and finishing times were recorded by the operating room nurse). The surgeon (Variable 41) was subgrouped according to the level of training of the actual operator, i.e., student, house officer I, II, etc., and staff physician. Immediate morbidity (Variable 48) was subdivided into standard morbidity, one-day fever, nonfebrile morbidity, and any combination of the above. Standard morbidity was defined as a temperature of 38’ C. (100.4O F.) or greater on any two of the first 10 postoperative days exclusive of the day of operation. A one-day fever was considered as a temperature elevation to 37.8’ C. (100.0’ F.) or greater on any single day. Any patient given prophylactic antibiotics was excluded from the study. Frequency Lrariable,
distributions and
respect
to
might
predispose
each
were subgroup
morbidity to
constructed
for
each
was
analyzed
with
so as to identify
factors
which
morbidity.
Prepared
public
Volume Number
I?? 6
Table
III.
Female
Gynecologic
Table
history 1
History Abnormal uterine bleeding Salpingitis Stress urinary incontinence Pelvic relaxation Cervical stenosis Pelvic pain Dysmenorrhea Dyspareunia Other
Table
IV. Previous
pelvic
26.1 2.7 8.1 4.5 0.9 1.8 1.8 1.8 8.2
operations
Procedure
/
No. 9 4 2 1 2 19 20
/ % of total
8.2 3.6 1.8 0.9 1.8 17.1 18.0
Results During the period studied (five and a half years), 1,757 female sterilizations were performed, of which 111 (6.3 per cent) were accomplished by vaginal hysterectomy. Table II details the variables descriptive of the patient population. The findings show that the usual patient was a married, white, multiparous woman in the mid-30’s. In recent years there has been increasing enthusiasm for vaginal hysterectomy as a method of sterilization at our institution. This is documented by the finding that 21.6 per cent of cases were performed in the first 2vz years of the study as compared with 78.4 per cent of the cases in the latter three years, 56.8 per cent of cases being done in the year 1970 alone. However, a similar exponential rise in the frequency of other female sterilizing operations also has been noted in our institution.
695
1-
Febrile Onestanday dard + fever + TlO?l-
Cause
Nonfebrile
febrile
standard
day fever
WlOT-
7?lO7-
bidity
bidity
bidity
17 16 4 0 0 0 2 6 45
14 1 0 2 1 3 1 15 37
1 0 1 0 0 0 0 0 T
1 0 1 0 0 0 0 0 -2
1 0 0 0 0 0 1 0 2
Urinary tract infection Pelvic cellulitis Pelvic abscess Pulmonary Thrombophlebitis Bleeding Other Unknown Total
Table
loll-
One-
VI. Modalities
febrile
of treatment
Treatment
computer programs of the Statistical Research Laboratory of the University of Michigan were used for all statistical analyses. Categorical variables were compared with the use of the chi-square analysis with the Yates correction. Comparisons between analytical variables were analyzed with Student’s t test or a one-way analysis of variance, as appropriate. Probability values were calculated from a two-tailed table, and only values of P < 0.05 were considered significant.
III
morbidity
% of total
No. 29 3 9 5 1 2 2 2 9
Gastrointestinal with infection Gastrointestinal without infection Cesarean section Tubal Ovarian Dilatation and curettage Other or combinations
V. Immediate
sterilization.
Antibiotics Antibiotics + drainage Antibiotics + adnexal procedure Transfusion + operation to control cuff bleeding Transfusion + vaginal pack Total
I
No. 44 5 5 1 1 56
Although most procedures (73.4 per cent) were done six months or more after a patient’s most recent delivery or abortion, 10.8 per cent were done in the puerperium. This latter group includes three therapeutic abortions with sterilization accomplished by vaginal hysterectomy. The indication for sterilization was socioeconomic and/or multiparity in 68.5 per cent; medical, in 20.7 per cent; psychiatric, in 4.5 per cent; genetic, in 4.5 per cent; and previous cesarean section, in 1.8 per cent of cases. Twenty per cent of the patients were using no form of contraception; 57 per cent, oral contraceptives; 14 per cent, an intrauterine contraceptive device; and 9 per cent, foam or a mechanical contraceptive. Tables III and IV summarize the previous gynecologic history and previous surgical history of the study group. Forty-five per cent of the patients had no significant past gynecologic history. The commonest abnormalities noted were abnormal uterine bleeding and pelvic relaxation. Fifty-one per cent of the patients had previous pelvic operations. The com-
rnonest procedurr wits dilatation and curettage alone or in combination with another operation. ‘I’he mean anesthesia time was 128 minutes (range == 70 to 260; standard deviation [S.D.] = 39), while the mean operating time was 98 minutes (range =p 35 to 233; SD. = 39). Most patients received general anesthesia (97.3 per cent). The operating surgeon was most commonly a senior individual, 87.4 per cent being third- or fourth-year house officers and 9 per cent being faculty members. Sixty-nine patients (62.2 per cent) had only vaginal hysterectomy performed, while 35 (31.5 per cent) had vaginal plastic procedures, 3 (2.7 per cent) had ovarian procedures, and 4 (3.6 per cent) had other additional operative procedures. The performance of associated surgery had a significant effect on several variables. The anesthesia time was increased by 29.4 minutes (t = 3.8; P = 0.0001). Vaginal plastic procedures were performed on more white than black patients (33.3 versus 15 per cent) (chi square = 2.6; P, not significant [N.S.]) , and estimated blood loss (EEL) greater than 250 ml. was significantly more common (chi square = 8.2: P = 0.0033) if associated surgical procedures were performed. The question of morbidity was examined in great detail (Table V) . Only 22 patients (20.0 per cent) escaped morbidity, while 35 (40.9 per cent) had standard morbidity, 37 (33.6 per cent) had one-day fevers, and two each (1.8 per cent) had nonfebrile morbidity, standard morbidity plus nonfebrile morbidity, or one-day fever plus nonfebrile morbidity. As an explanation for morbidity, urinary tract infection was diagnosed 34 times; pelvic cellulitis, 17 times; pelvic abscess, 6 times; cause of morbidity unknown, 21 times; and some other complication, 10 times. Most morbidity responded satisfactorily to antibiotics or some other medical modality of management (Table VI). However, additional surgical procedures were necessary in 11 cases ( 10 per cent of total series). Vaginal or abdominal drainage was utilized in addition to antibiotics in five cases; five patients required bilateral salpingo-oophorectomy in order to control postoperative pelvic infection, and one patient required resuturing of the vaginal cuff. Immediate morbidity was compared to all other variables in an attempt to identify significant correlations which might aid in anticipating morbidity. Immediate morbidity was more common at Wayne County General Hospital than at the University Hospital (chi square = 7.2; P = 0.027). Morbidity
was significantly higher if vaginal hysterectoriiy was performed during the puerperium. All 21 patients operated upon during the puerperium had febrile morbidity (chi square = 6.2; P = 0.0065). Morbidity did not correlate with the time in the menstrual cycle at which the operation was donr, anesthesia or operating time, the performance of associated procedures, the level of training of the surgeon, the quarter of the year in which operation was performed, or any other variables analyzed. Although there was a trend suggesting that less morbidity had occurred in recent years (50 per cent morbidity in the first two and a half years versus 38.4 per cent in the most recent three years), the difference was not significant at the 5 per cent level. The average length of hospitalization for all patients was 9.5 days with the shortest stay being four days and the longest 31 days. The length of stay was significantly affected by whether or not a vaginal plastic procedure was performed. This associated procedure added 3.6 days to the hospital stay (t = 3.63; P = 0.0005). The occurrence of morbidity also significantly lengthened the hospital stay. Febrile morbidity added 3.0 days to the stay and nonfebrile (chi square = 2.65; P = 0.0095)) morbidity added 8 days to the hospital stay (chi square = 2.40; P = 0.0184). The estimated blood loss showed a positive correlation with performance of associated surgical procedures, anesthesia time, operating time, and the relationship of the procedure to the most recent pregnancy (P = 0.0087, 0.0016, 0.0001, and 0.0379, respectively). Again there was no correlation with the level of training of the surgeon or with the cycle day on which the procedure was performed. Operative complications were uncommon. There were two bowel injuries, one bladder injury, and 18 instances of blood loss exceeding 500 ml. The bladder injury and bowel injuries (one small bowel and one large bowel below the peritoneaf reflection) were all repaired vaginally. One third of the 18 whom excessive blood loss occurred patients in required transfusion. Seventy-four per cent of the patients were seen on one or more occasions at some time later than six weeks after operation. Only 9 (11.1 per cent) patients have had additional problems. There were three instances of repeated urinary tract infection, three instances of emotional problems, one bartholin’s gland cyst, one ovarian cyst, and one vaginal mass. These latter two problems required a major
Volume Number
122 G
Female
and a minor correction.
additional
operative
procedure
for
Comment
An ideal method of female sterilization is one with a short operating time, short hospital stay, low blood loss and transfusion requirement, low rates of morbidity and operative complications, and a minimum of late sequelae. During this same period of five and a half years, 820 other interval female sterilizations were performed by other methods. When compared to these alternative procedures, vaginal hysterectomy does not seem ideal. The average operating time for laparoscopic tubal ligation was 33.1 minutes; for colpotomy tubal ligation, 43.3 minutes; for abdominal tubal ligation, 64.7 minutes; and for abdominal hysterectomy, 128 minutes. Vaginal hysterectomy required a significantly longer (P = 0.001) operating time than any of these except abdominal hysterectomy. The average length of hospital stay for laparoscopic tubal ligation was 3.4 days and that for colpotomy tubal ligation was 4.3 days, which is significantly shorter (P = 0.001) than the 9.5 days required for vaginal hysterectomy. The estimated blood loss is also significantly less in those patients undergoing interval laparoscopic tubal ligation and colpotomy tubal ligation (P < 0.001). Only 20.4 per cent of our patients undergoing vaginal hysterectomy escaped morbidity, and 42.7 per cent experienced standard morbidity. This compares with a standard morbidity rate of 1.5 per cent for laparoscopic tubal ligation, 5.7 per cent for colpotomy tubal ligation, 20.7 per cent for abdominal tubal ligation, and 45.2 per cent for abdominal hysterectomy. All of these rates except that for abdominal hysterectomy differ significantly from those for vaginal hysterectomy.
sterilization.
Ill
697
The very high incidence of febrile morbidity associated with vaginal hysterectomy stimulated Ledger and associates” to examine the role of prophylactic antibiotic therapy for such cases at our institution. They found that prophylactic cephaloridine (three intramuscular doses of 1 Gm. eachon call to the operating room, on return to the floor. and at bedtime the evening of operation) reduced standard morbidity from 46 to 24 per cent (P < 0.025). We had hoped to be able to identify a particularly high-risk group of women so that antibiotic prophylaxis could be reserved for them. Unfortunately, the only factors identified were the hospital and the length of time since the last pregnancy. This is in sharp contrast to our findings with tubal ligation via colpotomy where operating time and excessive blood loss correlated significantly with postoperative morbidity.’ Because of the above findings, for the past several years, it has been our practice to administer prophylactic antibiotics to almost all premenopausal women undergoing vaginal hysterectomy in the hope of reducing standard morbidity to the range of 20 to 25 per cent. Thus, in summary, our experience indicates that vaginal hysterectomy is not an ideal method of female sterilization. It is attended by significant morbidity, prolonged hospitalization, a long operating time, and significant blood loss. We feel that it should be used only in highly selected patients where there is a clear indication for hysterectomy above and beyond the desire for sterilization. We wish to acknowledge the able assistance and guidance of Esther Schaeffer, Statistical Research Laboratory, University of Michigan, Ann Arbor, Michigan.
REFERENCES
1. Atkinson, 2.
S. J., and Chappell, 39: 759, 1972. Van Nagell, J. R., and Raddick, GYNECOL.
3.
Hibbard, 1972.
S. B.: Ohstet. J. W.: AM
Gynecol. J. OBSTET.
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4. Roach, C. .J., Krolak,
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J. D., Powell,
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A. S., and Deuhler, K. F.: AM. J. OBSTET. GYNECOL. 114: 670, 1972. Schulman, H.: Obstet. Gynecol. 40: 738, 1972. Ledger, W. J., Sweet, R. L., and Headington, J. T.: AM. 1. OBSTET. GYNECOL. 115: 766. 1973. Rowe: R. E., Laros, R. K., and WGk, B. A.: AM. J. OBSTET. GYNECOL. 112: 1031, 1972.
