We were delighted to read Dr Patel’s comments supporting the idea that 24-hour day case vaginal hysterectomy has the potential to address rising NHS costs, while also helping to solve the logistical problems of inpatient bed shortages.1 We also agree with Dr Patel that patient satisfaction is an important factor when considering a new service development. The primary objective of our study was to report the experiences we gained in developing this service rather than patient satisfaction (although the superb informal patient feedback was very reassuring). We are currently looking at patient satisfaction of 24-hour day case vaginal hysterectomy in another study.
We are grateful for Dr Alfhaily’s interest in our paper.2 Since this was a new service development and extreme clinical caution was applied, a readmission rate of 6.2% (4 of 65) is acceptable. Dr Alfhaily quoted unanticipated admission rates of 1.4–7.8%. These rates are for a variety of ambulatory procedures and not just for 24-hour day case vaginal hysterectomies and so are not comparable.3,4
We strongly disagree with Dr Alfhaily’s statement that carrying out day case hysterectomies in parallel with traditional inpatient vaginal hysterectomies would confuse the nursing staff. The application of protocols and care pathways would easily avoid this problem. This has never been a problem for our highly skilled and innovative nursing colleagues in Cardiff. We also disagree with Dr Alfhaily’s suggestion that a lower cost of providing health care leads to a lower quality of service. This is often not the case in NHS service development. If we may adapt Dr Alfhaily’s analogy, a £ 500 transatlantic flight is often no better than a £ 300 flight.
We found Dr Onwude’s letter interesting, but due to the lack of references, it is not a critical appraisal as defined by evidence-based medicine, it is simply a personal opinion.5 We suggest Dr Onwude reviews the definition of evidence-based medicine. We agree it is important to consider the methodology of all scientific papers and use the best available evidence, but it is not good practice to just disregard observational studies. Dr Onwude has suggested several methodological problems with the study including a lack of a comparative population. Dr Onwude was also concerned with the title of the paper but has ignored the fact that the title contains ‘observational study’. Trying to critically appraise an observational study as you would a comparative study is illogical and is not good evidence-based practice. The exclusion and inclusion criteria are clearly presented in the text.
Our study represents the activity of one consultant’s team. The criticism that the consultant has always assisted the registrar is clearly inappropriate, as a significant proportion of the operations were carried out under indirect supervision by the consultant as per Royal College of Obstetricians and Gynaecologists recognised training methods. A high proportion of the registrars who received training on this firm have developed into consultants who regularly perform nonprolapse vaginal hysterectomies. There is also an implication that the patients represented a highly selected group. We point out that the corresponding number of nonprolapse inpatient vaginal hysterectomies and total abdominal hysterectomies for the studies time frame was 1–2 per year. The total number of hysterectomies is low due to use of other therapeutic options including endometrial ablation. We are delighted that the BJOG editorial review does not share Dr Onwude’s opinion of observational studies.
Although we can explain in written format our enthusiasm for vaginal hysterectomy followed by 24-hour postoperative stay, we would encourage the sceptics/forward thinkers to visit our unit or participate in a vaginal hysterectomy training course.