Measuring the outcomes of gynaecological surgery

Measuring the outcomes of surgery for gynaecological cancer is straightforward, for women and their surgeons will agree that length of survival and survival to five years are the most important. For benign gynaecological conditions however women may disagree with their surgeons about the success of treatment: thus a woman may be apparently cured of stress incontinence on urodynamic testing but may still complain of incontinence. Ray Garry and his colleagues (pages 44–54) describe a series of 57 women with severe endometriosis treated by radical laparoscopic excision, in which the outcome was measured by the women using three validated instruments (the Short Form 12, the EuroQOL EQ-5D and the sexual activity questionnaire developed by Thirlaway) and one unvalidated questionnaire developed by the authors. The immediate surgical results were good, all 57 operations being completed laparoscopically with only one woman sustaining a serious complication, treated successfully at the time of the operation. The questionnaires reveal that the women were moderately or severely ill before their operation, that laparoscopic excision of the endometriosis significantly improved their health four months later, but that their health was still impaired compared with the population. All dimensions of sexual activity were improved, and the authors' own questionnaire showed that pain with menstmation, pelvic pain, painful intercourse and rectal pain were also greatly relieved. Ray Garry and his colleagues conclude that radical laparoscopic excision is an effective treatment for advanced endometriosis, and suggest that it is preferable to drug therapy and hysterectomy which are unable to eradicate deposits of deep infiltrating endometriosis outside the uterus. More importantly this paper tells us how to measure the outcome of gynaecological surgery for benign disorders. It is often considered by gynaecologists that information obtained by a questionnaire is ‘subjective’ and therefore of less value than ‘objective’ assessments, such as urodynamic measurements after surgery for stress incontinence. In fact the opposite is true, for three of the questionnaires in this study are known to be reliable and valid, while nothing is known of the reliability of urodynamic measurements. The definitive assessment of the outcome of gynaecological surgery is the women's perceptions of her disease and its treatment using psychometric measurements, not our own perceptions of the disease and its treatment using physiological measurements.