Hysterectomy for benign* indications, irrespective of surgical technique, more than doubles the risk of requiring subsequent stress-urinary-incontinence surgery (SUIS). As such, women should be counselled on risks associated with hysterectomy, and other treatment options should be considered before surgery. These are the conclusions of authors of an Article in this week's edition of The Lancet.
However, an accompanying Comment examines how the Article contradicts previous studies, including by the same authors, and concludes there could be other reasons why the risk increases.
Many women choose hysterectomy because it offers definite cures to, among other conditions, irregular heavy menstrual bleeding, uterine prolapse, and postmenopausal bleeding. Incidence of hysterectomy-related illness post-operation is also low. By age 55, around one five British Women will have undergone hysterectomy.
Dr Daniel Altman, Danderyd University Hospital, Stockholm, Sweden, and colleagues did a 30-year study between 1973 and 2003 of 165260 Swedish women who had undergone hysterectomy (exposed group), and 479506 women who had not (unexposed group), matched by year of birth and area of residence. Occurrence of SUIS in both cohorts was established from the Swedish Inpatient Registry.
The researchers found that the risk of undergoing SUIS was 2.4 times higher in the exposed group compared with the unexposed group, irrespective of surgical technique. They found that the highest overall risk was within five years of hysterectomy, when patients in the exposed group were 2.7 times more likely than those in the unexposed group to require SUIS. The lowest risk was seen in patients more than 10 years after hysterectomy, when the risk was 2.1 times higher for exposed patients.
The authors say: "The most biologically plausible rationale for this association is surgical trauma caused when the uterus and cervix are severed from pelvic-floor supportive tissues at the time of hysterectomy. Hysterectomy could interfere with the intricate urethral sphincter mechanism-it might also result in changes of urethral and bladder neck support."
"We conclude that hysterectomy, irrespective of surgical technique, increases the risk for stress-urinary-incontinence surgery later in life, with multiparous** women at particular risk. Our findings have important public-health and clinical applications, in view of the many women undergoing hysterectomy for benign indications."
In the accompanying Comment, Dr Adam Magos, Royal Free Hospital, London, UK, looks at the contradictory results of Altman and colleagues' findings compared with previous studies. He says: "So, what is the truth" It seems likely that a simple hysterectomy does not adversely affect bladder function, at least initially, and indeed pre-existing symptoms may improve. If hysterectomy-induced urinary stress incontinence is a reality, it only becomes so several years after the surgery, as already suggested. Or perhaps it has nothing to do with hysterectomy, and women who agree to hysterectomy are just different in ways that we do not yet understand."
Notes to editors: *Benign indications are ones which will not lead to the development of cancer or other life-threatening conditions.
**Multiparous women are women who have given birth to more than one child vaginally, ie. not through caesarean section.
Dr Daniel Altman, Danderyd University Hospital, Stockholm, Sweden T) +46-70-742 40 62 E) daniel.altman@ds.se
Dr Adam Magos, Royal Free Hospital, London, UK T) +44 (0) 20 7794 0500 E) a.magos@medsch.ucl.ac.uk
The paper associated with this release can be viewed at the link below:
http://multimedia.thelancet.com/pdf/press/Hysterectomy.pdf
Journal
The Lancet