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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

We set out to determine the current status of training in vaginal hysterectomy in the UK. In total, 255 year 4 or 5 ‘Calman’ trainees were identified and sent an anonymous questionnaire assessing surgical experience, quality of training and attitudes towards vaginal hysterectomy. Our results demonstrate that senior trainees' experience in vaginal as opposed to abdominal hysterectomy is relatively poor. Despite this, trainees believed that the majority of hysterectomies should be done vaginally, and only a minority, laparoscopically.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Hysterectomy is currently the most common major elective operation in the world, with more than 70,000 hysterectomies performed annually in England alone.1 In the UK, 20% of women will have a hysterectomy by the age of 55, and an even higher proportion in the USA. The literature suggests that many of these cases could be managed by vaginal hysterectomy and indeed that this should be considered the route of choice.2 Despite this, 70% of hysterectomies for benign disease in the UK and most other countries are still performed abdominally, vaginal hysterectomy being largely reserved for cases of genital prolapse. A small proportion are being managed laparoscopically, and this has remained constant over the last decade.1,2

Why are relatively few hysterectomies done by the vaginal route despite evidence in the literature that this is the optimum technique for removing the uterus? The issue of training (or lack thereof) has been raised by several authors as being an important factor, lack of exposure in vaginal surgery leading to gynaecologists having a preference for abdominal (or laparoscopic) hysterectomy.3

To ascertain whether this is a contributory factor to the relatively low rate of vaginal hysterectomies in the UK, we assessed the views and experience of specialist registrars in the latter part of their training. We wanted to determine if it is that junior doctors have sufficient training in vaginal surgery but decide that abdominal hysterectomy is a better option in the main or that they believe that vaginal hysterectomy is best but their training does not allow them to put this into practice.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

UK is divided by the Royal College of Obstetricians and Gynaecologists (RCOG) into 22 training regions. The regional college advisors for each region were approached and asked to provide the names and contact details of trainees in Calman years 4 and 5, that is, specialist registrars in the two years prior to completion of specialist training, following which they are expected to take up consultant positions within the National Health Service.

Every trainee was sent an anonymous questionnaire containing 14 items assessing experience in the three different types of hysterectomies, factors currently limiting the place of vaginal hysterectomy and the potential effect of further training on their future practice.

In addition, records were gathered from two units within one region (North Thames) to ensure that self-reporting of procedures was consistent with quantitative data. Patients undergoing hysterectomy for benign disease were identified from computerised theatre records. Those who underwent subtotal hysterectomy or vaginal hysterectomy with prolapse repair were excluded, leaving a group of women who potentially could have had either abdominal or vaginal hysterectomy. The clinical notes for these patients were reviewed and the route and the grade of surgeon performing and assisting at hysterectomy were recorded.

Data were analysed using Mann–Whitney, Fisher's exact and χ2 tests. A P value of 0.05 or less was considered statistically significant.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Twenty of the 22 Regional Advisors replied and identified 255 Calman specialist registrars in years 4 or 5. Of these trainees, 172 (67.5%) replied to our questionnaire. Six of the respondents proved to be in year 3 of their training and were therefore excluded, leaving 166 responses for analysis. Sixty-six respondents were from year 4, 82 from year 5 and 18 were ‘old-style’ senior registrars. All but three trainees had passed the examination for membership of the RCOG in London.

There were marked differences in trainees' surgical experience in performing different hysterectomy types and a very similar pattern for assisting. Overall, three-quarters (75%) of respondents had performed more than 50 abdominal hysterectomies, while more than a third (34%) had performed less than 10 vaginal hysterectomies for an indication other than prolapse (P < 0.0001). Less than 10% had performed greater than 10 laparoscopic hysterectomy procedures (of all types) (P < 0.0001). For all hysterectomy routes, there was a trend towards senior registrar's having more surgical experience than year 5 trainees. Although in the main this difference was not statistically significant, the exception was for vaginal hysterectomy for an indication other than prolapse where 12/18 senior registrars compared with 30/82 year 5 specialist registrars had performed more than 30 cases (P= 0.03).

Currently, 45% of trainees would not consider vaginal hysterectomy if oophorectomy (BSO) is required, while nearly a third consider absence of prolapse to be a contraindication to vaginal surgery (Table 1). With sufficient training, 82% would be prepared to perform BSO at vaginal hysterectomy, while 96% would tackle a uterus >8/40 size at vaginal hysterectomy (Table 1).

Table 1.  Contraindications to vaginal hysterectomy currently and with further training. Results are expressed as n (%).
 CurrentFutureP
  • *.

    Statistically significant.

Nulliparity23 (13.8)8 (4.8)0.007*
Uterus > 8/4022 (13.3)6 (3.6)0.003*
Need for oophorectomy75 (45.1)30 (18.1)<0.0001*
Absence of prolapse34 (20.5)16 (9.6)0.009*
Previous lower segment caesarean section15 (9.0)8 (4.8)0.194
Previous pelvic surgery50 (30.1)45 (27.1)0.808
History of endometriosis85 (51.2)64 (38.6)0.027*
None of the above37 (22.3)72 (43.4)<0.0001*

The majority of respondents had seen vaginal hysterectomy performed when oophorectomy is indicated (64%), in the absence of uterine descent (81%), in a nulliparous patient (80%) and in patients with a history of previous caesarean section (77%). Although most trainees (83%) had seen bisection of the uterus to facilitate vaginal hysterectomy, far fewer had experience of other uterine reduction techniques such as myomectomy (only 43%), coring (13%) or morcellation (16%). A significant minority (16%) had no personal experience of any of these techniques.

In the trainees' opinion, 30% of hysterectomies should be done abdominally, 60% vaginally and 10% with laparoscopic assistance. Forty-seven trainees (28%) believed laparoscopic hysterectomy is never indicated.

Overall, 12.2% of trainees rated their training in vaginal hysterectomy as poor, 28.7% adequate, 36% good and 23.1% excellent. Seventeen of 18 senior registrars rated their training as good or excellent, compared with 55/81 year 5 trainees (P= 0.02) and 15/65 year 4 trainees (P < 0.0001, year 4 vs 5, P= 0.0005).

In the two year period surveyed, after exclusions, a total of 146 hysterectomies were performed for benign disease in the two units assessed. The clinical records of this group were reviewed. Of these, 137 had abdominal hysterectomy, 94 combined with bilateral salpingo-oophorectomy, while only nine women had vaginal hysterectomy, all with conservation of the ovaries. In total, 42 (30.6%) of abdominal and 5 (55.5%) of the vaginal hysterectomies were performed by year 4 and 5 senior registrars. In a further 25 women who had abdominal and 1 woman who had vaginal hysterectomy, year 4 and 5 senior registrars assisted the principal surgeon. During the study period, 13 year 4 and 5 senior registrars worked in the two units with the mean number of procedures, combined, per individual ranging from just over five per surgeon for abdominal hysterectomy and less than one per surgeon for vaginal hysterectomy.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Our study suggests that senior trainees experience in vaginal compared with abdominal hysterectomy is relatively poor. Despite this, trainees believed that the majority of hysterectomies should be performed vaginally, and only a minority, laparoscopically. Improving training in vaginal hysterectomy would potentially significantly increase the number of hysterectomies performed by the vaginal route.

Currently, many gynaecologists reserve the vaginal approach for the management of genital prolapse despite convincing evidence in the literature that features such as nulliparity, lack of prolapse, previous pelvic surgery, uterine enlargement or a need for oophorectomy should not be regarded as contraindications to vaginal surgery. Clinical practice is however largely determined by training and personal experience, rather than on evidence-based medicine. For example, Kovac et al.3 found that surgeons with a preference for the vaginal route are more likely to assess uterine mobility and size as part of their pre-operative assessment, as they recognise the importance of these two variables in terms of successful vaginal surgery.

Our study suggests that there is a willingness among trainees to widen their indications for vaginal hysterectomy. Increasing or improving training would lead a greater number of trainees to consider vaginal hysterectomy for enlarged uteri or where oophorectomy is indicated, in the absence of prolapse and for the nulliparous patient. This is confirmed by Davies et al. who demonstrated that training gynaecologists to treat women with moderate uterine enlargement and to perform oophorectomy at vaginal hysterectomy would lead to a major rise in the rate of vaginal hysterectomy.4 Encouragingly, in our survey, the majority of respondents had surgical experience of debulking techniques, and nearly two-thirds had at least seen vaginal oophorectomy.

However, to gain confidence in surgical techniques, trainees need both quality and quantity of surgical cases. Herein may lie the problem. In general surgery, it has been estimated that the introduction of Calman training and reduction in junior doctors hours has resulted in a decrease in practical surgical training by 60%,5 whereas a recent survey by the RCOG reported that 36% of trainees expressed dissatisfaction with the number of surgical procedures that they were performing.6 This represented an increase of approximately 50% on the previous survey. A fifth also rated operative teaching as very poor or poor.6 In our study, a significantly higher proportion of senior registrars rated their training in vaginal hysterectomy as good or excellent compared with trainees in years 4 and 5. Furthermore, year 4 trainees self-rated their training poorer than those in year 5, which reinforces the impression that changes in the structure of specialist training may be adversely affecting surgical experience. In the VALUE national hysterectomy study, registrar's and senior registrars performed a mean of 12 and 16 hysterectomies of all types per doctor between 1994 and 1995.1 The authors postulated that these figures were likely to decrease in the future. In the same study, only 22% of hysterectomies for disease confined to the uterus (in the absence of prolapse) were performed vaginally. These figures are consistent with both the number of hysterectomies self-reported in our questionnaire and the quantitative data we collected over two years. In addition, we achieved almost 70% response rate to our survey, which compares favourably with other published questionnaire surveys of clinical practice. This suggests that our findings represent an accurate reflection of the current status of surgical training in hysterectomy.

In conclusion, to gain the advantages associated with vaginal hysterectomy demonstrated by the literature and recognised by the trainees, senior clinicians have a difficult task to provide adequate training in vaginal surgery, a situation that is compounded by the reduction in the training period as a result of the Calman changes and decreased junior doctors hours. Perhaps, one way of doing this would be to develop clinical guidelines for route of hysterectomy at national or local level. Introduction of this kind of guideline in other settings has been demonstrated to increase the proportion of vaginal hysterectomies and enhance surgical training.7

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The authors would like to thank all the regional advisors who kindly provided details of trainees in their regions and the trainees themselves who responded.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  • 1
    Maresh MJA, Metcalfe MA, McPherson K, et al. The VALUE national hysterectomy study: description of the patients and their surgery. Br J Obstet Gynaecol 2002;109: 302312.
  • 2
    Report by the Health Technology Information Assessment Service of ECRI. Laparoscopy in Hysterectomy for Benign Conditions. Plymouth Meeting,Pennsylvania: HTIAS, 1995.
  • 3
    Kovac SR, Christie SJ, Bindbeutel GA. Abdominal versus vaginal hysterectomy: a statistical model for determining physician decision making and patient outcome. Med Decis Mak 1991;11: 1928.
  • 4
    Davies A, Vizza E, Bournas N, O'Connor H, Magos A. How to increase the proportion of hysterectomies performed vaginally. Am J Obstet Gynecol 1998;179: 10081012.
  • 5
    Crofts T, Griffiths J, Sharma S, Wygrala J, Aitken R. Surgical training: an objective assessment of recent changes for a single health board. BMJ 1997;314: 891895.
  • 6
    Royal College of Obstetricians and Gynaecologists.. Survey of Training. London: RCOG, 1997.
  • 7
    Kovac SR, Barham S, Lister M, Tucker L, Bishop M, Das A. Guidelines for the selection of the route of hysterectomy: application in a resident clinic population. Am J Obstet Gynecol 2002;187: 15211527.

Accepted 25 March 2004