Hysterectomy for benign conditions in a university hospital in Saudi Arabia.

Of 251 women who met the inclusion criteria, 199 (79%) had an abdominal hysterectomy (AH), including 22 who had a subtotal hysterectomy. Fifty-two (21%) had a vaginal hysterectomy (VH), including 3 patients who had a laparoscopic-assisted VH. No statistically significant differences were found between the groups in medical problems, preoperative hemoglobin, body weight, preoperative and postoperative hospital stay, operative time, type of anesthesia, and use of prophylactic anticoagulation agents ( Table 1 ). An estimated blood loss of ≥500 mL was found in 104 patients (52.3%) in the AH group and 20 patients (38.5%) in the VH group (not statistically significant). Of the 159 women (63.3%) younger than 50 years, 140 (70.4%) had an AH and 19 (36.5%) had a VH ( P 2 in 208/251 (82.8%) of the patients. Sixty-two (24.7%) women had a history of previous laparotomy when performing the hysterectomy, and the majority of those women (55/62, 88.7%) had the procedure done abdominally. A prophylactic antibiotic was given to all except 16 women who had an AH (235, 93.6%), and the majority of women did not receive prophylactic anticoagulation (209, 83.3%). The most common indication for hysterectomy was a uterine fibroid (n=107, 41.6%); all except two of these cases were performed abdominally ( Table 2 ). Dysfunctional uterine bleeding (DUB) was the cause for 68 (27.1%) of the hysterectomies performed. The most common indication for VH was uterine prolapse (n=45, 86.5%). Forty (77%) women who had a VH underwent vaginal wall repair (anterior or posterior or both) and only 5 had an oophorectomy at the same time, while 136 (63.3%) who had an AH underwent removal of one or both ovaries at the same time ( Table 3 ). No significant differences in medical problems were found between the AH group and VH group, and 154 patients (61.4%) had no major medical disease ( Table 4 ). Intraoperative and postoperative complications occurred in 9.7% (n=24) and 20.3% (n=51) of the total population ( Tables 5 ). The most common intraoperative complication was blood transfusion, which occurred in 18 patients, (7.2% of the total population), including 15 patients (7.5%) in the AH group and 3 (5.8%) in the VH group; the difference was not statistically significant. The risk of bladder, ureteric and bowel injury was 0.8%, 0.4% and 1.2%, respectively. These occurred only in the AH group. Postoperative infection occurred in 47 (18.7%) patients, including 42 (21.6%) in the AH group and 5 (9.6%) in the VH group (difference not statistically significant). There were no cases of vaginal cellulites or pelvic abscess in either group. Only 3 women developed postoperative deep vein thrombosis (DVT) with a rate of 1.2%, all of which occurred after AH. Overall, only 42 patients (42/251, 8%) received prophylactic anticoagulation. No statistical correlation between the use of anticoagulant and the occurrence (or non occurrence) of DVT was found ( P =.4). Four patients (1.6%) required ICU admission because of intractable bleeding, one in the VH group and 3 in the AH group. Only two (one from each group) required re-operation. None of our study population experienced life-threatening events such as æintraoperative or postoperative cardiac or respiratory pulmonary embolism, myocardial infarction or disseminated intravascular coagulation. There were no anesthesia complications, no cases of wound dehiscence and no postoperative incisional hernias in our study population.

Hysterectomy is one of the most common operations done in women, with an expected lifetime prevalence of 10%. 8 In this descriptive study we compared the indications and complications of AH versus VH. We had a total of 251 women who had had a hysterectomy over a 13-year period. AH accounted for 79% and VH for 21% of hysterectomies, coinciding with previous reports. 4 , 9 , 10 We found that the most common indication for VH was uterine prolapse (86.5%), which occurs mostly in women greater than 50 years old, while the most common indications for AH were uterine fibroids and DUB (84.5%) which mostly occur in women less than 50 years old. The incidence of intra-operative complications in our study population was 9.7%, similar to previous studies, which report 2% to 11%. 12 , 13 AH had more intra-operative complications than VH; 10.5% and 5.8% as shown in Table 5 . Nevertheless, the difference did not reach statistical significance. The need for blood transfusion is the major category of intraoperative complication in our study. The total incidence was 7.2% and no significant difference was noted between the AH and VH group (7.5%) and (3%) ( P =.66). Ten women who required blood transfusion (55%) had a hysterectomy for a uterine fibroid. We found that this rate of blood transfusion was higher than previously reported in similar studies, 1 , 4 , 5 and that might contribute to the fact that most of our hysterectomies were for large uterine fibroids and DUB, procedures that tend to be bloody, in patients who already had low hemoglobin preoperatively. Febrile morbidity was the most prevalent of the postoperative complications in our study. The overall rate for fever was 13.9% with a trend toward more febrile events among AH patients compared with VH patients (15.1% vs 9.6%, respectively, P >.05). We were unable to demonstrate the benefits of antibiotic prophylaxis in reducing febrile morbidity because of the small number of patients who did not receive antibiotic prophylaxis. However, randomized controlled trials support the use of prophylactic antibiotics to significantly reduce postoperative infectious morbidity. 14 , 15 The overall complication rates were 33.5%, 15.4% and 30.4% in women who underwent AH, VH and both, respectively. However, if we exclude the patients who had a blood transfusion, the overall complication rate was 22.7%, which is similar to the international rate. 4 , 11 An analysis of 160 000 hysterectomies in Ohio found a complication rate of 9.1% for abdominal and 7.8% for vaginal operations. 16 We found that there were no statistically significant differences between pre- and postoperative hospital stay, use of anesthesia, preoperative hemoglobin level, the presence of medical problems, previous laparotomy, age and overall complication rate. However, there was a trend toward more complications occurring in the AH group, since AH is usually done for high-risk indications, i.e. fibroid, pelvic mass, and endometriosis. This study described a large series of hysterectomies performed in a single teaching institution in Saudi Arabia, providing information about morbidity in relation to the type of operative approach. It provides physicians with information on which to base advice about the expected local rate of complications before planned surgery. We found that the rate of complications was not different from other centers internationally.

Between January 1990 and December 2002, patients who had a hysterectomy for a benign gynecological condition at King Abdulaziz University hospital (KAUH), Jeddah, Kingdom of Saudi Arabia, were identified using the KAUH database. and patient medical records for those patients were reviewed. Data from the medical records for those patients were collected and entered into a study database for analysis. Patients who had a hysterectomy done for a benign gynecological condition based on the final histopathology report. Patients with a pre-invasive disease were also included. Patients with a diagnosis or history of cancer, patients who had an emergency hysterectomy for peripartum hemorrhage and patients who had a major co-procedure like thyroid, heart, breast, stomach, gallbladder, and colon and kidney surgery were excluded from the study. The procedures were performed by senior residents and registrars under the supervision of 20 different consultant gynecologists with different levels of existe. The data collected included patient demographics, presence of medical problems, previous laparotomy, pre- and postoperative hemoglobin, indications for hysterectomy, associated gynecological procedures, the use of prophylactic antibiotic and anticoagulation and intra- and postoperative complications, including hospital stay. Data were collected and entered into the statistics computer program NCSS 2000 for analysis. The Chi square test was used for statistical comparison and a P value of less than .05 was considered to be significant.