Department of Obstetrics and Gynecology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.
Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
Acta Obstet Gynecol Scand. 2023 Jun;102(6):774-781. doi: 10.1111/aogs.14561. Epub 2023 Apr 3.
Hysterectomy is a frequently performed gynecological procedure but long-term effects remain understudied. Pelvic organ prolapse reduces life quality significantly. The lifetime risk of undergoing pelvic organ prolapse surgery is 20% and parity is known to be the largest risk factor. Studies have shown an increased risk of pelvic organ prolapse surgery after hysterectomy; however, few have studied the compartments which are affected and how this association is affected by surgical route and parity.
In this Danish nationwide cohort study, we identified women born in 1947-2000 who underwent hysterectomy during 1977-2018 who were indexed on the day of hysterectomy. We excluded women who immigrated when older than 15 years, who underwent pelvic organ prolapse surgery prior to index, and who were diagnosed with a gynecological cancer prior to or within 30 days of index. Women who underwent hysterectomy were matched 1:5 to references on age and year of hysterectomy. Women were censored at the time of death, emigration, a gynecological cancer diagnosis, radical or unspecified hysterectomy or December 31, 2018, whichever came first. The risk of pelvic organ prolapse surgery after hysterectomy was computed using Cox proportional hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, calendar year, parity, income and educational level.
We included 80 444 women who underwent hysterectomy and 396 303 reference women. Women who underwent hysterectomy had a significantly higher risk of undergoing pelvic organ prolapse surgery: HR 1.4 (95% CI 1.3-1.5). In particular, the risk of a posterior compartment prolapse operation was increased: HR 2.2 (95% CI 2.0-2.3). The risk of prolapse surgery increased with increased parity and by an additional 40% after hysterectomy. Cesarean sections did not seem to increase the risk of prolapse surgery.
This study shows that hysterectomy, regardless of surgical route, leads to an increased risk of pelvic organ prolapse surgery, especially in the posterior compartment. The risk of prolapse surgery increased with the number of vaginal births, and not cesarean sections. Women should be thoroughly informed about the risk of pelvic organ prolapse and other treatment options should be considered before choosing hysterectomy to treat benign gynecological diseases -particularly women who have had numerous vaginal births.
子宫切除术是一种常见的妇科手术，但长期效果仍有待研究。盆腔器官脱垂显著降低生活质量。盆腔器官脱垂手术的终生风险为 20%，而分娩次数是最大的风险因素。研究表明，子宫切除术后发生盆腔器官脱垂手术的风险增加；然而，很少有研究涉及受影响的部位，以及这种关联如何受到手术途径和分娩次数的影响。
在这项丹麦全国性队列研究中，我们确定了 1947 年至 2000 年出生的妇女，她们在 1977 年至 2018 年期间接受了子宫切除术，并在子宫切除术当天被索引。我们排除了在 15 岁以上移民、索引前接受盆腔器官脱垂手术以及索引前或索引后 30 天内诊断为妇科癌症的妇女。接受子宫切除术的妇女按年龄和子宫切除术年份与对照 1:5 匹配。妇女在死亡、移民、妇科癌症诊断、根治性或未特指的子宫切除术或 2018 年 12 月 31 日（以先发生者为准）之前被删失。使用 Cox 比例风险比（HR）和 95%置信区间（CI）计算子宫切除术后盆腔器官脱垂手术的风险，调整年龄、日历年、分娩次数、收入和教育水平。
我们纳入了 80444 名接受子宫切除术的妇女和 396303 名对照妇女。接受子宫切除术的妇女行盆腔器官脱垂手术的风险显著增加：HR 1.4（95%CI 1.3-1.5）。特别是后盆腔脱垂手术的风险增加：HR 2.2（95%CI 2.0-2.3）。分娩次数增加，子宫切除术后风险增加 40%。剖宫产似乎不会增加脱垂手术的风险。
本研究表明，子宫切除术（无论手术途径如何）都会导致盆腔器官脱垂手术的风险增加，尤其是在后盆腔。脱垂手术的风险随着阴道分娩次数的增加而增加，而不是剖宫产。在选择子宫切除术治疗良性妇科疾病之前，应向妇女充分告知盆腔器官脱垂的风险，并应考虑其他治疗选择-特别是那些有多次阴道分娩的妇女。
