Of all the gynecological operations, hysterectomy is one of the most common surgical procedures conducted all over the world. Hysterectomy is next only to cesarean section in women all over the world. There is a large variation in trends of hysterectomy in different parts of the world. Between 10-20 % of women have hysterectomy by the time they are 60 years old in developed countries [1], whereas in developing country like India hysterectomy prevalence ranges between 0.2-6.3 per 100 women in age group 15-49 years with mean age at 36 years [2]. There was strong evidence that women of reproductive age with lower income and at least 2 children underwent hysterectomy at higher rates. Women who have bilateral oophorectomy consistently report higher frequency of hot flashes and vulvo vaginal atrophy due to hormonal withdrawal [3].

Hysterectomy can be done for many benign conditions like fibroid, adenomyosis, polyp, premalignant lesions and also is done in malignant conditions like carcinoma arising from cervix, uterus or ovaries [4]. Some hysterectomies are often performed in obstetric emergencies like placenta accrete syndrome or intractable post-partum hemorrhage to save patient’s life. 

Traditionally hysterectomy was done by either abdominal or vaginal route. Recently there is propensity towards hysterectomy being done by minimally access surgery route, so patients prefer laparoscopic or robotic hysterectomy instead of abdominal hysterectomy. The reason for popularity of minimally invasive surgeries is, less postoperative pain, early postoperative recovery and reduced adhesion formation, but the laparoscopy / robotics has long learning curve for surgeon and disadvantage of inability to retrieve solid organs. Variations in surgical techniques has been introduced to reduce operative and post-operative effects of hysterectomy on the urinary and sexual function [5]. The complications of hysterectomy have also decreased over the years with the advent of new less invasive techniques that give magnified view, use of preoperative antibiotics and patient awareness. There is always a disagreement on genuine valid cause for performing hysterectomy [6]. 

The current study was carried out to find and analyze the trend of hysterectomy, route of hysterectomy, indications of surgery in the suburban population and trend change over the years. The aim of the study is to assess the type of hysterectomy with indication of surgery and prevalence in the age group in the suburban population. The present study makes an attempt to analyze the trend in hysterectomy over past 6 years in a suburban tertiary center.    

This study was carried out in the department of obstetrics and Gynecology of a tertiary hospital in suburban part of UP, India. This was a retrospective observational study of 1411 patients who underwent hysterectomy from 1st January 2014 to 31st December 2019 as the year 2020 was influenced majorly by COVID-19. Case records were taken from hospital medical record section; consent was taken from the competent authority. All operations were done using standard surgical technique by senior gynecologists. Data regarding age, parity, religion, Indication for hysterectomy and route of surgery was obtained. Data collected was analyzed using descriptive statistics based on the parameters of age, parity, indication, type of hysterectomy, oophorectomy done or not and presented in percentages. 

Data Analysis: Statistical analysis was performed using SPSS for windows version 16-0. 1.5 (SPSS software Chicago). Mean values were calculated shown with their standard deviation and 95% CI.

A total of 1411 patients underwent hysterectomies during a period of 6 years from 1st January 2014 to 31st December 2019.

Mean age group of patients was 44 years ranging from 30 years to 70 years. Most of the patients were from rural areas. In the present study most of the patients were in the age group 41-50 years (n=625(46.6%) whereas least were in the age group less than 30 years (n=43(3.05%) (Table 1).

The most common complaints included heavy menstrual bleeding, dysmenorrhea, something coming out of vagina and chronic pelvic pain. Majority of the patients underwent hysterectomy for benign conditions (n=1337(94.76%)), 56 out of 1411(3.96%) were done for malignant conditions whereas only 18 out of 1411 (1.28%) underwent hysterectomy for obstetrics reasons (Table 2).

Among the benign indications majority of women underwent hysterectomy for fibroid uterus (730/1411(51.73%)), second common indication was prolapsing uterus (406/1411(28.77%%)), 124 out of 1411 (8.78) underwent hysterectomy because of adenomyosis. 32 (2.26%) hysterectomy were done for chronic pelvic inflammatory disease. Out of 1411 hysterectomy 20(1.41%) were done for ovarian mass which looked suspicious. 17 out of 1411(01.2%) underwent hysterectomy for bleeding uterus polyp and 8 out of 1411 underwent hysterectomy for endometriosis not controlled on medical management (Table 3).

AUB –Abnormal uterine bleeding- Adenomyosis; AUB-L: leiomyoma, AUB P: Polyp; PID: Pelvic inflammatory disease.

Among the patients who underwent hysterectomy for malignant conditions majority patients had carcinoma ovary 23 out of 1411 (1.63%) followed by carcinoma endometrium 22 out of 1411(1.6%) and carcinoma cervix 11out of 1411(0.8%) (Table 4).

In the present study total 18 out of 1411 (1.28%) underwent hysterectomy for obstetric indication. Among the obstetric hysterectomies 8(0.56%) were performed for intractable PPH, 5 (0.35%) were performed for uterine rupture, 3(0.21%) for post septic abortions with septic peritonitis and 2 (0.14%) were performed for adherent placenta (Table 5).

In the present study maximum number of hysterectomies were performed by vaginal route (including non-descent vaginal hysterectomies). A total of 721 hysterectomy out of 1411(51.09%) were performed by vaginal routes. All vaginal hysterectomies performed for uterine prolapse were associated with pelvic floor repair. A total of 666 out of 1411 (47.2%) hysterectomies were performed abdominally,24 out of 1411(1.72%) were performed laparoscopically, 18 out of 1411 (1.27%) were performed for obstetric indication. 3 out of 1411 (0.21%) were radical hysterectomy performed for malignancy. 645 out of 1411 (45.71%) abdominal hysterectomies were performed for benign indications (Table 6).

Table 1: Distribution of patients according to age group (n=1411)

Table 2: Distribution based on indication of hysterectomy

Table 3: Indications for hysterectomy in Benign conditions

Table 4: Indications for hysterectomy in Malignant conditions

Table 5: Indications for obstetric hysterectomy

Table 6: Distribution by type of hysterectomy

Hysterectomy is the most common gynaecological surgery done worldwide in women. Hysterectomy is common in western world as compared to India where it is roughly 4-6 %; of these about 75% of hysterectomy are done in age group between 20-49 years [7]. In the present study, mostly patient was in the age group 41-50 years.Most of the women had parity ranging from 1 – 3. 

In the present study majority of the patients underwent hysterectomy for benign conditions (1337 out of 1411 (94.76%). In USA 91.7% hysterectomy are for benign causes. Of all the hysterectomies performed in present study 1.27 % were for obstetric reasons, reasons being placenta accrete, intractable post-partum haemorrhage and uterine rupture. It was reported the most common indication of doing emergency obstetric hysterectomy being ruptured uterus followed by atonic PPH [8]. In the present study intractable PPH 0.56 % was most common reason for emergency hysterectomy.

In current study 3.96 % of hysterectomies were performed for malignancy. Among benign conditions majority of the women underwent hysterectomies for fibroid uterus (51.73%) and prolapse uterus (28.77%), which was the second most common cause. In another study it was found that commonest indication was fibroid (26%) followed by AUB [9]. Heavy menstrual bleeding was the main indication for hysterectomy in most of the studies as it was in this study. 

Hysterectomy can be done via vaginal, abdominal, laparoscopic or robotic route. Abdominal route is associated with longer hospital stay, increased complications and higher morbidity. but due to the lack of training habits and faster operating practicing style, most of the gynecologists still continue to use abdominal and vaginal approaches over laparoscopic approach [10]. Since vaginal hysterectomy carries least risk and complications it is encouraged for prolapse uterus and even in non-descent uterus where size of uterus is up to 8 to 10 weeks with lax vagina. 

Trend of hysterectomy is on a rise nowadays. The introduction of laparoscopy in gynecological surgeries has changed hysterectomy trends dramatically. The proportion of hysterectomy performed laparoscopically in the USA has increased significantly during last 20 years from 0.3% in 1990 to 11.8 % in 2003 [11]. Regardless of this abdominal route remains to be the mostly common choice worldwide. Recent trends showed a rise in number of laparoscopic surgeries as it was seen in present study.

Decision of subtotal hysterectomy is made by surgeon based on patient condition and wish. Subtotal hysterectomy is done more in obstetrics emergencies like atonic PPH whereas total is indicated in cases of low-lying placenta with adherent placenta. Total abdominal hysterectomy has its own limitation, it can cause sexual dysfunction due to shortened vaginal cuff, higher blood loss and increased risk of uterovaginal prolapse and complications of wound healing. Laparoscopic approach also has increased risk of urologic injuries and cautery related injuries.

In UK and USA 60-80% of the hysterectomies are done by abdominal route [12]. In this study 45.71% of hysterectomy were done by abdominal route and 51.09% of hysterectomies were done by vaginal route.

Anemia and weakness secondary to blood loss due to surgery has a negative impact on quality of life. A large multicentric retrospective study in US by CDC showed that the rate of complications is 1.7 times more in abdominal hysterectomy [13]. 

It is recommended the tubes should be removed and ovaries spared atleast till the natural age of menopause is achieved as terminal portion of tubes are nidus for premalignant precursor STIC (serous tubal intraepithelial carcinoma) lesions. In the present study 131 out of 522 (25.09%) patients underwent salpingectomy when ovaries were spared. The merit of doing concurrent salpingectomy continues to be debated. In a study it was reported that estimates regarding the number of prophylactic oophorectomies needed to prevent one case of ovarian cancer ranges from 200-300 [14].

The ideal choice of route of hysterectomy should be based on patients’ clinical presentation, experience, skill of the surgeon and patient preferences. The surgical route should be safe while providing adequate treatment and optimal medical care. Although the benefits of minimally invasive surgery have been well documented, all options of surgical approach should be readily available to the patients. Proper training of gynecologists may influence the decision-making process in favor of minimally invasive techniques. Further research is needed to understand the trends in hysterectomy in various geographic locations.

The most common indication of hysterectomy in suburban population is abnormal uterine bleeding with Fibroid uterus. Vaginal route is the commonest approach for hysterectomy and is countered with least intraoperative and postoperative comorbidities. Recent surgical trends showed a significant shift towards Minimally Invasive Surgery like Laparoscopic approach for hysterectomy. The surgical route should be safe while providing adequate treatment and optimal medical care.

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