Summary
- Menorrhagia (excessive menstrual bleeding) and uterine myomas (fibroids) are common conditions in women in their reproductive years. Their treatment accounts for 5,300 and 6,500 hysterectomies per year respectively in Australia.
- Hysterectomy (abdominal or vaginal) in Australia is associated with eight to nine days in hospital and recovery periods of several weeks. Estimated financial costs (i.e. costs to health service providers) are $3,550 to $3,739 per patient.
Endometrial resection/ablation
- Endometrial resection/ablation are hysteroscopic techniques that minimise menstrual blood loss by destroying the endometrial lining. This can be done using a diathermy loop (resection) or by ablation with a diathermy ball, a laser or a radiofrequency device. The procedure is successful in most cases, although some patients require a repeat treatment or undergo subsequent hysterectomy.
- Endometrial resection/ ablation is generally day surgery or followed by one to three days in hospital, with a recovery period of two to three weeks.
- The financial cost per patient of endometrial resection is estimated at $1,510. Estimated laser and radiofrequency ablation costs are higher at $2,178 and $2,490 per patient respectively, due to higher equipment costs.
- Diathermy resection/ablation has cost advantages and is effective in comparison with abdominal hysterectomy. It is diffusing rapidly throughout Australia.
- Outcomes from laser ablation are similar to those from diathermy resection/ablation, but costs are higher and its use in Australia is limited to date.
- Little information about outcomes from radiofrequency ablation is available. Given a similar cost to laser ablation, diathermy resection/ ablation will remain more cost-effective unless a significantly greater advantage in terms of increased success rates or lower morbidity can be demonstrated for radiofrequency ablation.
- Endometrial ablation by photodynamic therapy is a new technique that is still experimental.
Laparoscopically-assisted hysterectomy
- Laparoscopically-assisted hysterectomy refers to the use of a laparoscope to ligate some or all of the uterine vessels and ligaments. The uterus is removed through the vagina. The main role of the procedure is to allow an abdominal hysterectomy to be performed vaginally.
- Laparoscopic hysterectomy refers to the performance of the entire hysterectomy laparoscopically, and is unlikely to become common.
- In comparison with abdominal hysterectomy, laparoscopically-assisted hysterectomy reduces postoperative pain, shortens hospital stays to one to four days and recovery periods to one to four weeks.
- The financial cost of laparoscopically-assisted hysterectomy has been estimated at $2,963 per patient. Of this, about $1,200 is for disposable instruments.
Myomectomy
- Myomectomy provides an alternative to hysterectomy for those women wishing to preserve their fertility. Both open and laparoscopic myomectomy are technically more difficult than hysterectomy, and the laparoscopic approach has very limited application.
- Short-term results of hysteroscopic myomectomy are similar to endometrial resection, but the procedure is technically more difficult.
Medical therapies
- A range of medical therapies are available, but are generally only effective for the duration of therapy and are associated with side effects.
- Preoperative endometrial suppression is useful prior to endometrial resection/ ablation. The new gonadotropin-releasing hormone (GnRH) agonists are promising in this application, although more expensive than alternatives.
Conclusions
- Endometrial resection or ablation using diathermy could replace most of the 5,300 abdominal hysterectomies done annually for menorrhagia. Laser and radiofrequency ablation are unlikely to replace the diathermy techniques to any significant extent.
- Laparoscopically-assisted hysterectomy could replace many of the abdominal hysterectomies done annually, including some of those done for myomas. Its effect on vaginal hysterectomy will be less significant.
- Hysteroscopic myomectomy may be performed more commonly in conjunction with endometrial resection/ablation. Otherwise, myomectomy will remain limited to fertility-preserving applications.
- Further information is required about:
- long-term retreatment rates for endometrial resection/ ablation
- success, safety and cost-effectiveness of laparoscopically-assisted hysterectomy compared with abdominal hysterectomy
- success and safety of radiofrequency ablation.
- Issues that need addressing include:
- suitable training and accreditation processes to ensure safe introduction and use of these new procedures
- cost-effectiveness of disposable versus reusable instruments
- effects on hospital infrastructure of these new procedures, particularly in terms-of decreased bed use and impact on theatre time.