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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 2  |  Page : 184-187

Hysterectomies pattern at a tertiary healthcare center, northern Nigeria


1 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Histopathology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication17-Aug-2018

Correspondence Address:
Dr. Afolabi K Koledade
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJOG.TJOG_16_18

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  Abstract 

Background: The uterus is an important female genital organ for menstrual and reproductive functions. However, there are various gynecologic and obstetric indications for carrying out hysterectomy.
Objectives: To determine the indications and the patterns of hysterectomies done at Ahmadu Bello University Teaching Hospital, Zaria Nigeria.
Materials and Methods: 5-year retrospective descriptive study on patients who had hysterectomy done from 2011 to 2015.
Results: The age range of the patients was 2–70 years with a mean of 48.6 ± 8.8 years. Hysterectomies constituted 19.3% of total gynecology surgeries done during the same period. Of these total abdominal hysterectomy 144 (87.8%) was the most common, next was vaginal hysterectomy with pelvic floor repair 13 (7.9%), and then subtotal hysterectomy was 7 (4.3%). The most common indication for total abdominal hysterectomy was multiple uterine fibroids, a benign uterine tumor.
Conclusion: Hysterectomy is a common gynecological surgery which may be used to treat benign uterine pathologies, especially when there is no more desire for conception. It could also be lifesaving in uncontrollable postpartum hemorrhage as well as malignant pelvic organ pathologies, especially in early stages.

Keywords: Gynecological surgery; hysterectomy, pattern; uterine fibroids.


How to cite this article:
Koledade AK, Oguntayo AO, Zayyan MS, Avidime S, Samaila MO, Adesiyun AG. Hysterectomies pattern at a tertiary healthcare center, northern Nigeria. Trop J Obstet Gynaecol 2018;35:184-7

How to cite this URL:
Koledade AK, Oguntayo AO, Zayyan MS, Avidime S, Samaila MO, Adesiyun AG. Hysterectomies pattern at a tertiary healthcare center, northern Nigeria. Trop J Obstet Gynaecol [serial online] 2018 [cited 2018 Dec 12];35:184-7. Available from: http://www.tjogonline.com/text.asp?2018/35/2/184/239155


  Introduction Top


The uterus is an important female genital organ for menstrual and reproductive functions. However, there are indications for carrying out hysterectomy on a patient which must be clear and communicated to the patient preoperatively for appropriate consent. Commonly factors considered include cervical, uterine, and ovarian pathologies which may be benign or malignant. Also of important consideration is the age of the patient, parity, and completion of family size. Hysterectomy could also be deployed as a life-saving procedure in the treatment of postpartum hemorrhage, ruptured uterus, and complications of unsafe abortion, thereby playing a role in the reduction of maternal mortality especially in the developing countries.[1],[2] Hysterectomy may involve removal of the tubes and ovaries, or be more extensive and radical especially in malignant indications or may be supracervical also known as subtotal. In the cases of subtotal hysterectomies, patients would be followed up with periodic cervical cancer screening because unlike those who undergo total hysterectomies, they are still susceptible to cervical cancer.

The approach to hysterectomy may be abdominal, vaginal, or laparascopic and this is mostly determined by the patient's clinical presentation and surgical skills. In Nigeria, the ratio of vaginal hysterectomy to abdominal hysterectomy varies from 1:4 to 1:9 which like in most developing countries is lower than that observed in developed nations.[3],[4],[5]

This study sought to assess the clinicopathological indications and pattern of hysterectomies done at Ahmadu Bello University Teaching hospital Zaria.


  Materials and Methods Top


Theatre and histopathology records of patients who had hysterectomy from 2011 to 2015 were reviewed and the data generated were subjected to analysis using SPSS version 20 (IBM, Armonk, NY, United States of America). Hysterectomies done without histology report were excluded.


  Results Top


The total gynecological surgeries done within the study period were 850 with hysterectomies constituting 19.3%. Total abdominal hysterectomy 144 (87.7%) was the most common hysterectomy variant, next was vaginal hysterectomy with pelvic floor repair 13 (7.9%) and then subtotal hysterectomy was 7 (4.3%) [Table 1].
Table 1: Pattern of hysterectomies done

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A total of 6 (3.7%) were done on emergency basis. Three cases each for obstetrics and gynecology emergencies, respectively. The age range of the patients was 26–70 years with a mean of 48.6 ± 8.8 years.

Benign indications were the most 114 (79.7%) while malignant was 29 (20.3%). From neoplasia point of view neoplastic indications for hysterectomy was 143 (87.2%), while nonneoplastic was 21 (12.8%).

The commonest indication for total abdominal hysterectomy was symptomatic multiple uterine fibroids 71 (43.3%), a benign uterine tumor. These include cervical fibroids [Table 2]a.
Table 2a: Indications for hysterectomy.
Table 2b: Other indications for hysterectomy



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Indication for vaginal hysterectomies and pelvic floor repair was uterovaginal prolapse 12 (92.3%) except for one (7.7%) with chronic uterine inversion [Table 2]b.

The vast majority of the hysterectomies 159 (96.9%) had a Consultant as the lead surgeon, while the rest 5 (3.1%) had a Senior registrar as the lead surgeon. All the vaginal hysterectomies and pelvic floor repair were done by Consultants with the exception of one (7.7%) done by a Senior registrar.


  Discussion Top


Hysterectomy is one of the common gynecological surgeries at ABUTH Zaria. A total of 164 hysterectomies were done within the 5-year study period (2011–2015) comparable with 317 found by Samaila et al. done over 10 years (1995–2005) in the same center.[6] It constitutes 19.3% of total gynecology surgery done during the study period. This is higher than 16.4% found in a similar study in NAUTH Nnewi but much lower than 5.1% found at AKTH Kano.[3],[7]

The commonest indication for total abdominal hysterectomy was symptomatic multiple uterine fibroids 71 (43.3%) similar to 45.4% found in Ile-Ife southwest Nigeria, slightly higher than 39.1% found in Gombe northeast Nigeria and lower than 66.4% in Kano, and 53.3% found in a study at a private specialist hospital in southeast Nigeria. This may be due to delayed fertility as a result of increasing uptake of higher education among women in northern Nigeria cities notably Zaria which has a number of tertiary institutions. Malignant indications were 29 (20.3%) greater than 12.9% found in Ile-Ife.[7],[8],[9],[10]

The age range of the patients was 2–70 years with a mean of 48.6 ± 8.8 years which is slightly higher than 44.6 years found in earlier study at the same centre and 45.7 years found in Gombe but much lower than 56.6 years found in Ibadan, southwest Nigeria and 65.2 years in Nnewi, southeast Nigeria. The mean age found in a study at a private specialist hospital in Nnewi Anambra state southeast Nigeria was 45.5 years.[3], 6, [9],[10],[11]

Age and completion of family size are strong determinants for consenting to hysterectomy; however, these considerations may not hold in those that had emergency hysterectomy (mean age 33.3 ± 5.5 years) and those who had malignant indications for hysterectomy. It is worthy to note that most of the indications for emergency hysterectomy in obstetrics have advanced maternal age as risk factors, viz ruptured uterus.

Emergency hysterectomies were 6 (3.7%) lower than what Onwuhafua et al. found in five (10.6%) in and audit of hysterectomies in a group private clinics in Kaduna [Table 2]b.[1]

Vaginal hysterectomy was 7.9% of all hysterectomies done which is much lower than 20.9% in Kano and 20.7% found in northeast Nigeria compared to 10% at JUTH Jos and 21% at NAUTH Nnewi.[3],[12] High fertility rate found in this regions is a risk factor for genital prolapse a foremost indication for vaginal hysterectomy in developing countries.[5],[7],[9]

Indication for vaginal hysterectomy was essentially genital prolapse (92.3%) in this study compared with a study in Ibadan where genital prolapse constituted 81.8%. There may be a need to expand the indication for vaginal hysterectomy in our hospitals beyond genital prolapse in view of its advantages like absence of abdominal scar, less postoperative morbidity, short hospital stay, and therefore reduced cost.[3],[11]

Unilateral or bilateral salpingoophorectomy either as treatment or prophylaxis for ovarian cancer was done in up to 125 (76.2%) comparable to 79% found in the Gombe study. This is so because though ovarian function in most women ends on the average of 50 years of age and the significant drop in estrogen has impact on the their wellbeing with respect to the cardiovascular system, central nervous system, bone mass index, there is no organized screening program for cancers including ovarian cancer; hence, low-resource settings like ours most cancer cases present in advanced stages. Ignorance may also be a contributory factor to such late presentation.[9],[13],[14]

Considerations for some of the premenopausal patients who had unilateral salpingoophorectomy either right or left was to keep an ovary to provide estrogen thereby preventing surgical menopause and the menace of its symptoms and signs but such considerations are for benign indications.

Majority of the hysterectomies were performed by the consultant cadre with only five (3.1%) done by Senior registrars. In as much as this pattern contributes to quality assurance of the surgeries, there is the need for more residents to be exposed under supervision to the surgeries in order to build better capacity before being certified Consultants.

Less patients benefited from regional anesthesia 50 (30.5%) despite its benefits of relatively less complications, earlier return of bowel functions, shorter hospital stay, and so on [Table 3].
Table 3: Anesthesia by hysterectomy approach

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Worthy of note is that of the 13 patients who had vaginal hysterectomy nine (69.2%) had general anesthesia (GA), three (23.1%) spinal, and one (7.7%) had combined GA and spinal compared to a vaginal hysterectomy study in Jos study which revealed spinal anesthesia administered to 30 (66%); GA to 13 (30%), while 2 (4%) had their spinal anesthesia converted to GA.[4]

The 13 (7.9%) patients who had combined spinal and general anesthesia as well as 1 (0.6%) who had combined spinal, epidural, and GA were as a result of failed regional anesthesia or surgeries that got prolonged than anticipated. Ordinarily combined spinal and epidural anesthesia have complimentary advantages like early onset of action of spinal anesthesia, lower doses of anesthetic agents as well as postoperatively pain management from epidural top-ups.[15]


  Conclusion Top


Hysterectomy is a common gynecological surgery which may be used to treat benign upper female genital organ pathologies especially when there is no more desire for conception. It is also useful in malignant pelvic organ pathologies especially in early stages or following neoadjuvant chemotherapy. It could also be lifesaving in uncontrollable postpartum hemorrhage. Residents and Specialists should be trained and retrained respectively on the benefits of vaginal hysterectomy as an option for nonprolapse indications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Onwuhafua PI, Oguntayo AO, Adesiyun AG, Obineche I, Akuse JT. Audit of hysterectomies in a group of private hospitals in Kaduna City, northern Nigeria. Trop J Obstet Gynaecol 2005;22:16-20.  Back to cited text no. 1
    
2.
Adesiyun AG, Zayyan MS, Ameh CA. Ruptured Uterus in a Tropical Teaching Hospital: Choice of Surgical Treatment versus Maternal Outcome. J Turkish-German Gynecol Assoc 2008;9:144-8.  Back to cited text no. 2
    
3.
Obiechina NJ, Ugboaja JO, Onyegbule OA, Eleje GU. Vaginal hysterectomy in a Nigerian tertiary health facility. Niger J Med 2010;19:324-5.  Back to cited text no. 3
    
4.
Daru PH, Pam IC, Shambe I, Magaji A, Nyango D, Karshima J. Vaginal Hysterectomy at Jos University Teaching Hospital, Jos, Nigeria. J West Afr Coll Surg 2011;1:26-36.  Back to cited text no. 4
    
5.
Okeke TC, Ikeako LC, Ezenyeaku CCT. Underexposure of Residents in Training in the Art of Vaginal Hysterectomy in Nigeria. Am J Clin Med Res 2014;2:22-5.  Back to cited text no. 5
    
6.
Samaila MOA, Adesiyun AG, Agunbiade OA, Mohammed-Duro A. Clinico-pathological assessment of Hysterectomies in Zaria. Eur J Med 2009;6:150-3.  Back to cited text no. 6
    
7.
Ahmed ZD, Taiwo N. Indications and Outcome of Gynaecological Hysterectomy at Aminu Kano Teaching Hospital, Kano: A 5-Year Review. Open J Obstet Gynecol 2015;5:298-304.  Back to cited text no. 7
    
8.
Orji EO, Ndububa VI, Ajenifuja KO. Elective Hysterectomy in Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. Sahel Med J 2002;5:125-8.  Back to cited text no. 8
  [Full text]  
9.
Bukar M, Audu BM, Yahaya UR. Hysterectomy for benign gynaecological conditions at Gombe, north eastern Nigeria. Niger Med J 2010;1:35-8.  Back to cited text no. 9
    
10.
Okafor CI, Okanwa U, Nwankwo M, Ezeigwe CO. A Review of Gynaecological Hysterectomies in a Private Specialist Hospital in Nigeria. Orient J Med 2012;24:3-4.  Back to cited text no. 10
    
11.
Bello FA, Olayemi O, Odukogbe AA. An audit of vaginal hysterectomies at the University College Hospital, Ibadan. Niger J Med 2011;20:426-31.  Back to cited text no. 11
    
12.
Ocheke AN, Ekwempu CC, Musa J. Underutilization of vaginal hysterectomy and its impact on residency training. West Afr J Med 2009;28:323-6.  Back to cited text no. 12
    
13.
Oguntayo AO, Zayyan MS, Koledade AK, Adewuyi SA. A pictorial Overview of Gynaecological Cancers in Northern Nigeria. Niger Postgrad Med J 2008;15:15.  Back to cited text no. 13
    
14.
Broekmans FJ, Soules MR, Fauser BC. Ovarian aging: Mechanisms and Clinical consequences. Endocr Rev 2009;30:465-93.  Back to cited text no. 14
    
15.
Malenkovic V, Zoric S, Randelovic T. Advantage of Combined spinal, Epidural and General Anaesthesia in comparison to General Anaesthesia in abdominal surgery. Srp Arh Celok Lek 2003;131:232-7.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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