Use of vaginal hysterectomy in Denmark: rates, indications and patient characteristics

The long-term association between bilateral oophorectomy and depression: a prospective cohort study

OBJECTIVE

Depression is a leading cause of disability globally and affects more women than men. Ovarian sex steroids are thought to modify depression risk in women and interventions such as bilateral oophorectomy that permanently change the sex steroid milieu may increase the risk of depression. This study aimed to investigate the associations between unilateral and bilateral oophorectomy and depression over a 25-year period (1993-2018) and whether this varied by age at oophorectomy or use of menopausal hormone therapy.

METHODS

Twenty-five thousand one hundred eighty-eight nurses aged ≥45 years from the Danish Nurse Cohort were included. Nurses with depression prior to baseline were excluded. Poisson regression models, with log-transformed person-years as offset, were used to assess the associations between oophorectomy and incident depression. Nurses who retained their ovaries were the reference group.

RESULTS

Compared with nurses with retained ovaries, bilateral oophorectomy was associated with a slightly higher rate of depression (rate ratio [RR], 1.08; 95% confidence interval [CI], 0.95-1.23), but without statistical significance. However, when stratified by age at oophorectomy, compared with nurses with retained ovaries, bilateral oophorectomy at age ≥51 years was associated with higher rates of depression (RR 1.16; 95% CI, 1.00-1.34), but not bilateral oophorectomy at age <51 years (RR 0.86; 95% CI, 0.69-1.07); P value for difference in estimates = 0.02. No association between unilateral oophorectomy and depression was observed.

CONCLUSIONS

In this cohort of Danish female nurses, bilateral oophorectomy at age ≥51 years, but not at younger ages, was associated with a slightly higher rate of depression compared with those who retained their ovaries.

Change in medical practice over time? A register based study of regional trends in hysterectomy in Finland in 2001-2018

Background

A persistent research finding in Finland and elsewhere has been variation in medical practices both between and within countries. Variation seems to exist especially if medical decision making involves discretion and the best treatment cannot be identified unambiguously. This is true for hysterectomy when performed for benign causes. The aim of the current study was to investigate regional trends in hysterectomy in Finland and the potential convergence of rates over time.

Methods

We used hospital discharge register data on hysterectomies performed, diagnoses, age, and region of residence to examine hospital discharges for women undergoing hysterectomy in 2001–2018 among total female population aged 25 years or older in Finland. We examined hysterectomy rates among biannual cohorts by indication, calculated age-standardised rates and used multilevel models to analyse potential convergence over time.

Results

Altogether 131,695 hysterectomies were performed in Finland 2001–2018. We found a decreasing trend, with the age-adjusted overall hysterectomy rate decreasing from 553/100,000 person years in 2001–2002 to 289/100,000 py in 2017–2018. Large but converging regional differences were found. The correlations between hospital district intercepts and slopes in time ranged from − 0.71 to − 0.97 (p < 0.001) suggesting diminishing variation.

Conclusions

Our findings demonstrate that change in hysterectomy practices and more uniformity across regions are achievable goals. Regional variation still exists suggesting differences in medical practices.

The effectiveness of surgical procedures to prevent post-hysterectomy pelvic organ prolapse: a systematic review of the literature

Introduction and hypothesis

Hysterectomy is one of the most commonly performed gynecological surgical procedures. One of the long-term risks associated with hysterectomy is the occurrence of pelvic organ prolapse (POP). To prevent post-hysterectomy POP, several suspension procedures are routinely performed at the time of hysterectomy. We performed a systematic review of published data in order to define the most effective surgical procedures for the prevention of post-hysterectomy POP.

Methods

We performed a systematic review of the literature by searching PubMed, the Cochrane Library, EMBASE, Ovid MEDLINE, and clinicaltrials.gov up to 24 May 2020. The search strategy included the keywords hysterectomy, post-hysterectomy, prolapse, colposuspension, culdoplasty, McCall, and combinations thereof. The inclusion criterion was a surgical procedure at the time of hysterectomy to prevent de novo POP. The outcome was incidence of post-hysterectomy POP.

Results

Six out of 553 retrieved studies met the methodological criteria for complete analysis. In this review, 719 women aged over 18 years were included. Only 2 studies were designed as prospective trials; however, only 1 compared women undergoing a procedure at the time of hysterectomy with controls. The prevalence of post-hysterectomy prolapse varied from 0% to 39%.

Conclusion

A systematic review of published literature suggests that performing variations of McCall culdoplasty at the time of hysterectomy might be the most effective prophylactic surgical procedure for preventing post-hysterectomy pelvic organ prolapse.

Electronic supplementary material

The online version of this article (10.1007/s00192-020-04572-2) contains supplementary material, which is available to authorized users

Surgical repair of vaginal vault prolapse; a comparison between ipsilateral uterosacral ligament suspension and sacrospinous ligament fixation-a nationwide cohort study

INTRODUCTION AND HYPOTHESIS

Hysterectomy is frequently performed and associated with increased risk of subsequent genital prolapse including vaginal vault prolapse. Ipsilateral uterosacral ligament suspension (IUSLS) and sacrospinous ligament fixation (SSLF) are two commonly performed surgical techniques to treat vaginal vault prolapse. There is no consensus on the ideal operation technique. The aim of this study was to compare IUSLS and SSLF to treat vaginal vault prolapse based on the number of repeat surgeries.

METHODS

Previously hysterectomized patients operated on with IUSLS or SSLF in Denmark in 2010-2016 were included in this nationwide register-based cohort study and followed until June 2017. Data were obtained from Danish National Databases, to which reporting is mandatory by law, entailing high validity and completeness of data. Data were analyzed using Cox proportional hazard regression analysis adjusted for age, preoperative prolapse stage, smoking, BMI, and previous prolapse surgery.

RESULTS

In total, 744 patients were included; 384 underwent IUSLS while 360 underwent SSLF. After 5 years, 6.5% of patients operated on with IUSLS and 21.8% operated on with SSLF had a repeat surgery in the apical compartment and 12.4% and 30.6% in any compartment, respectively. The risk of repeat surgery was 4.8 times higher after SSLF compared to IUSLS [confidence interval (CI): 2.7-8.4] in the apical compartment and 2.4 times higher (CI: 1.2-5.1) in the anterior compartment. No difference was seen in the posterior compartment.

CONCLUSIONS

This study finds significantly higher numbers of repeat surgeries after SSLF compared to after IUSLS in a Danish nationwide cohort.

Unnecessary bilateral salpingo-oophorectomy at the time of hysterectomy and potential for ovarian preservation

OBJECTIVE

To evaluate predictors of bilateral salpingo-oophorectomy at hysterectomy and determine rate of unnecessary bilateral salpingo-oophorectomy.

METHODS

Retrospective review of hysterectomies at six Ontario, Canada hospitals from July 2016 to June 2018. Data was extracted from health records coding and electronic medical records. Of patients with concurrent bilateral salpingo-oophorectomy, age, preoperative diagnoses, surgical factors (presence of endometriosis/adhesions), and surgeon training (fellowship/no fellowship) were recorded. Chi-square tests compared indicated and nonindicated bilateral salpingo-oophorectomy cases based on preoperative diagnosis. Criteria for unnecessary bilateral salpingo-oophorectomy were: age under 51 years, benign preoperative diagnosis, and absence of intraoperative endometriosis and adhesions.

RESULTS

Concurrent bilateral salpingo-oophorectomy occurred in 749/2,656 (28%) cases with 509/749 (68%) indicated based on preoperative diagnosis. There was interhospital variation in rate of indicated bilateral salpingo-oophorectomy based on preoperative diagnosis (45.3%-76.9%, χ2P < 0.001). Concurrent bilateral salpingo-oophorectomy at academic centers was more likely to have preoperative indications versus those at community hospitals (70% vs 63%, OR 1.42, 95% CI 1.02-1.97, P = 0.04). BSO performed by fellowship-trained surgeons were more likely to be indicated than those performed by generalists (75% vs 63%, OR 1.76, 95% CI 1.26-2.44, P = 0.001). Of patients without preoperative indications for bilateral salpingo-oophorectomy, 105/239 (44%) were under 51 years of age, of which 59 (58%) had no intraoperative endometriosis/adhesions. Ovarian preservation may have been reasonable in 8% (59/749).

CONCLUSIONS

Concurrent bilateral salpingo-oophorectomy performed by generalists and at community hospitals was less likely to have preoperative indications. Ovarian preservation was potentially possible for 8%.

Reduced Complications Following Implementation of Laparoscopic Hysterectomy: A Danish Population-based Cohort Study of Minimally Invasive Benign Gynecologic Surgery between 2004 and 2018

STUDY OBJECTIVE

To monitor and report nationwide changes in the rates of and complications after different methods for benign hysterectomy, operative hysteroscopy, myomectomy, and embolization in Denmark. To report the national mortality after benign hysterectomy DESIGN: National prospective, observational cohort study.

SETTING

The Danish Hysterectomy and Hysteroscopy Database.

PATIENTS

Women undergoing surgery for benign gynecologic diseases: 64 818 hysterectomies, 84 175 hysteroscopies, 4016 myomectomies, and 1209 embolizations in Denmark between 2004 and 2018.

INTERVENTIONS

National meetings with representatives from all departments, annual working reports of institutional complication rates, workshops, and national guideline initiative to improve minimally invasive surgical methods.

MEASUREMENTS AND MAIN RESULTS

Rates of the different methods and complications after each method with follow-up to 5 years as recorded by the database directly in the National Patient Registry. Nationwide, a decline in the use of hysterectomy, myomectomy, embolizations, and endometrial ablation. The total short-term complications were 9.8%, 7.5%, 8.9%, and 2.7% respectively, however, with a persistent risk of approximately 20% for recurrent operations within 5 years after endometrial ablation. Initially, we urged for increased use of vaginal hysterectomy, but only reached 36%. From 2010, we urged for reducing abdominal hysterectomies by implementing laparoscopic hysterectomy and reached 72% laparoscopic and robotic procedures. Since 2015, we used coring or contained morcellation for removal of large uterus at laparoscopic hysterectomy. The major and minor complication rates (modified Clavien-Dindo classification) were reduced significantly from 8.1% to 4.1% and 9.9% to 5.7% respectively. Mortality after benign hysterectomy was 0.27‰. The odds ratio for major complications after abdominal hysterectomy was 1.66 (1.52-1.81) compared to minimally invasive hysterectomy independent of the length of stay, high-volume departments, indications, comorbidity, age, and calendar year.

CONCLUSION

Fifteen years with a national database has resulted in a marked quality improvement. Denmark has 85% minimally invasive hysterectomies and has reduced the number of major complications by 50%.

The feasibility and safety of transvaginal bilateral salpingo-oophorectomy

OBJECTIVE

To investigate the feasibility and safety of transvaginal bilateral salpingo-oophorectomy (BSO).

METHODS

The present retrospective case series included consecutive women who underwent transvaginal BSO at a single general gynecology unit at Weston General Hospital, Weston-super-Mare, UK, between February 1, 2011, and July 31, 2014. Transvaginal BSO procedures were performed by an experienced surgeon. Feasibility and safety outcomes were reviewed from patient case notes.

RESULTS

There were 127 patients included in the analysis. In all, 109 patients underwent transvaginal BSO at the time of vaginal hysterectomy, whereas 18 women underwent this procedure following a previous vaginal hysterectomy. Transvaginal BSO was successful in 126 (99.2%) patients; adverse events occurred among nine (7.1%) patients, including a single occurrence of ureteric injury that was detected and repaired intraoperatively.

CONCLUSION

The present study demonstrated that transvaginal BSO was a feasible and safe procedure when conducted by an experienced surgeon.

The Danish Hysterectomy and Hysteroscopy Database

Aim of the database

The steering committee of the Danish Hysterectomy and Hysteroscopy Database (DHHD) has defined the objective of the database: the aim is firstly to reduce complications, readmissions, reoperations; secondly to specify the need for hospitalization after hysterectomy; thirdly to secure quality assessment of hysterectomy and hysteroscopy by setting standards and national guidelines; and finally to intensify the monitoring of laparoscopic surgery and explore long-term side effects after hysterectomy.

Study population

We include all women in Denmark who have had elective benign uterine surgery since 2003. The surgery includes hysterectomy and operative hysteroscopy. In the latter, we include resection of the endometrium and submucosal leiomyomas and ablations of the endometrium.

Main variables

Detailed information about the hysterectomy and hysteroscopy operation techniques, cooperations, and indications is registered directly in the National Patient Register (NPR), as well as relevant lifestyle factors and confounders. It is mandatory to register information about complications and readmissions in the NPR. Data included in DHHD are directly extracted from the NPR.

Descriptive data

Annually approximately 4,300 hysterectomies and 3,200 operative hysteroscopies are performed in Denmark. Since the establishment of the database in 2003, 50,000 hysterectomies have been registered. DHHD’s nationwide cooperation and research have led to national guidelines and regimes. Annual national meetings and nationwide workshops have been organized.

Conclusion

The use of vaginal and laparoscopic hysterectomy methods has increased during the past decade and the overall complication rate and hospital stay have declined. The regional variation in operation methods has also decreased.

Anti-hemorrhagic effect of prophylactic tranexamic acid in benign hysterectomy-a double-blinded randomized placebo-controlled trial

BACKGROUND

Hysterectomy is one of the most frequently performed major gynecological surgical procedures. Even when the indication for the procedure is benign, relatively high complication rates have been reported. Perioperative bleeding seems to represent the most common cause of complications and in 2004, 8% of all women in Denmark undergoing benign hysterectomy experienced a bleeding complication. Tranexamic acid is an antifibrinolytic agent that has shown to effectively reduce bleeding complications within other surgical and medical areas. However, knowledge about the drug's effect in relation to benign hysterectomy is still missing.

OBJECTIVE

To investigate the antihemorrhagic effect of prophylactic tranexamic acid in elective benign hysterectomy.

STUDY DESIGN

A double-blinded randomized placebo-controlled trial was conducted at 4 gynecological departments in Denmark from April 2013 to October 2014. A total of 332 women undergoing benign abdominal, laparoscopic, or vaginal hysterectomy were included in the trial, randomized to either 1 g of intravenous tranexamic acid or placebo at start of surgery. Chi-square test and Student t test statistical analyses were applied.

RESULTS

The primary outcome of intraoperative total blood loss was reduced in the group treated with tranexamic acid compared to the placebo group when estimated both subjectively by the surgeon and objectively by weight (98.4 mL vs 134.8 mL, P = .006 and 100.0 mL vs 166.0 mL, P = .004). The incidence of blood loss ≥500 mL was also significantly reduced (6 vs 21, P = .003), as well as the use of open-label tranexamic acid (7 vs 18, P = .024). Furthermore, the risk of reoperations owing to postoperative hemorrhage was significantly reduced in the tranexamic acid group compared to the placebo group (2 vs 9, P = .034). This corresponds to an absolute risk reduction of 4.2% and number needed to treat of 24. No incidence of thromboembolic events or death was observed in any of the groups.

CONCLUSION

The results support the hypothesis that prophylactic treatment with tranexamic acid reduces the overall total blood loss, the incidence of substantial blood loss, and the need for reoperations owing to postoperative hemorrhage in relation to benign hysterectomy. No incidences of serious adverse events occurred. Thus, tranexamic acid should be considered as a prophylactic treatment prior to elective benign hysterectomy.

Global epidemiology of hysterectomy: possible impact on gynecological cancer rates

Despite the fact that hysterectomy is the most common surgical procedure worldwide in gynecology, national reporting of the incidence rate of gynecological cancers rarely removes the proportion no longer at risk of the disease from the population-at-risk-denominator (ie, women who have had a hysterectomy). The incidence rate of gynecological cancers is thus likely underestimated. Because hysterectomy, as well as oophorectomy, incidence varies across countries, age, and over time, meaningful comparison of gynecological cancer incidence rates may be compromised. Without accurate estimates of gynecological cancer incidence rates, performed via removing the proportion of hysterectomized or oophorectomized women from the population-at-risk-denominator, the impact of prevention strategies may be masked or misinterpreted. Furthermore, because national cervical cancer screening guidelines are at least in part based on the national reporting of cervical cancer incidence, it is important that the incidence rate reflects the true population at risk.

Hysterectomy and its impact on the calculated incidence of cervical cancer and screening coverage in Denmark

BACKGROUND

The incidence rates of cervical cancer and the coverage in cervical cancer screening are usually reported by including in the denominator all women from the general population. However, after hysterectomy women are not at risk anymore of developing cervical cancer. Therefore, it makes sense to determine the indicators also for the true at-risk populations. We described the frequency of total hysterectomy in Denmark and its impact on the calculated incidence of cervical cancer and the screening coverage.

MATERIAL AND METHODS

With data from five Danish population-based registries, the incidence rate of cervical cancer and the screening coverage for women aged 23-64 years on 31 December 2010 were calculated with and without adjustments for hysterectomies undertaken for reasons other than cervical cancer. They were calculated as the number of cases divided by 1) the total number of woman-years from the general population; and 2) the at-risk population after exclusion of post-hysterectomy woman-years. Cases were defined as women with cervical cancer (incidence), or as women screened in the recommended interval, with or without adjustment for hysterectomies (coverage).

RESULTS AND CONCLUSIONS

In 2010, the all-age prevalence of hysterectomy was estimated at 6%, and ≥ 16% at age ≥ 65. This translated into an overall 6% increase in the incidence rate of cervical cancer, from 12.8 (unadjusted) to 13.5 (adjusted) per 100,000 woman-years. The screening coverage increased from 76% (unadjusted) to 79% (adjusted). In Denmark, hysterectomies do not have a large overall impact on the calculated cancer incidence and screening coverage. Nevertheless, at ≥ 65 years adjusted rates would increase by almost 20% compared to unadjusted rates. This suggests that calculating disease risks per organ-years may have a role in understanding the true burden of the disease in a population at risk of developing that disease.

Optimizing vaginal hysterectomy in women with large volume non-prolapse uteri: a novel minimally-invasive "aneurysm needle clampless technique"

OBJECTIVE

To describe and evaluate the safety and feasibility of a new clampless technique using aneurysm needle for vaginal hysterectomy compared with the standard technique as a less minimally-invasive procedure in women with benign large volume non-prolapse uteri.Study design In a pilot study, series of 46 consecutive women with benign large volume (200-500cm(3)) uterine conditions other than pelvic organ prolapse were planned for vaginal hysterectomy (VH). Patients were divided into 2 groups; group-A (21 women): for whom an (aneurysm needle clampless VH) was performed; group-B (25 women): used as a control (standard VH). Demographic characteristics and peri-operative parameters for both techniques were compared.Results Of the 46 vaginal hysterectomies, 44 were successfully performed (95.7%; 95% confidence interval, 91.6-99.4%). Two (4.3%) conversions were necessary from VH to open surgery [1 case in group A and another case in group B]. There was no statistically significant difference between both groups regarding the demographic data. Preoperative uterine volumes were comparable (232.8mL vs 226.0mL, respectively) (P>.05). The mean operative time was significantly shorter in the clampless VH group compared with the control group (70.14±7.78min vs 79.52±7.41min, respectively) (P=.007). No reported complications in our series.Conclusion Clampless VH using aneurysm needle represents a safe and less minimally-invasivepossible technique in women with benign large volume non-prolapse uteri. It takes a shorter operative.

Comparison of vaginal and abdominal hysterectomy:A prospective non-randomized trial

OBJECTIVE

To compare outcomes of vaginal and abdominal hysterectomy procedures in women with benign gynaecological diseases.

METHODS

This was a prospective study of outcomes of consecutive patients who underwent total vaginal hysterectomy (VH) or abdominal hysterectomy (AH) for benign gynaecological diseases. Patient characteristics before, during, and after the operations were reviewed. Patients were followed up for three months to evaluate postoperative complications.

RESULTS

This study included a total of 313 patients. 143 patients underwent AH and 170 patients underwent VH. Baseline characteristics were similar between the two groups. There were no intraoperative complications in either group. Operation time, intraoperative blood loss, first postoperative flatus time, time to out-of-bed activity, mean maximum postoperative body temperature, and duration of fever were all significantly shorter and less severe in the VH group compared with the AH group. In addition, vaginal length in the VH group was significantly shorter than in the AH group.

CONCLUSIONS

Vaginal hysterectomy has advantages over AH in the treatment of benign gynaecological diseases, providing greater efficacy and safety with minimal invasiveness.

Incidence and lifetime risk of pelvic organ prolapse surgery in Denmark from 1977 to 2009

INTRODUCTION AND HYPOTHESIS

The purpose of the study was to describe the incidence of pelvic organ prolapse (POP) surgeries in Denmark during the last 30 years, age distribution over time, and the lifetime risk of undergoing POP surgery.

METHODS

We carried out a population-based registry study. The setting was the Danish National Patient Registry. The sample consisted of Danish women of all ages undergoing prolapse surgery during the period 1977-2009. Data were retrieved from the Danish National Patient Registry. Prolapse surgery included surgery for any type of genital prolapse including hysterectomy due to prolapse. The main outcome measures were incidence of POP, age distribution over time, and lifetime risk of undergoing POP surgery.

RESULTS

Surgical interventions for POP decreased by 47 % from 1977 (288 procedures/100,000 women) to 1999 (153 procedures/100,000 women). Subsequently, they increased to 75 % of the original incidence rate; in 2008, the incidence of total POP procedures was 201 out of 100,000 women and the incidence of women undergoing POP surgery was 139 out of 100,000 women. During the study period, the age-specific incidence of POP surgeries increased for women over the age of 65-69 years and decreased for women below that age. In 2008, the lifetime risk for an 80-year-old woman of undergoing at least one POP surgery was 18.7 %.

CONCLUSIONS

The incidence of POP surgery varied up to 50 % during the study period. The age distribution changed so that more elderly and less young women had surgery in 2008 compared with 1978. Finally, we found that the lifetime risk of undergoing POP surgery for an 80-year-old was 26.9 % in 1978, 20.5 % in 1988, 17.2 % in 1998, and 18.7 % in 2008.

Cost-effectiveness of hysterectomy for benign gynecological conditions: a systematic review

The objective of this study was to assess the cost-effectiveness of hysterectomy performed for benign indications. Hysterectomy remains the most common major gynecological operation in the Western world. Rates of hysterectomy have not declined as expected with the introduction of new treatment options. Furthermore, use of laparoscopic techniques varies widely within the Nordic countries. We designed a systematic review in a University Central Hospital. The sample included all published studies regarding the cost-effectiveness of hysterectomy performed for benign indications (n = 1666). Medline, Cochrane Library, PsycINFO, CINAHL, and Nursing databases were searched. Inclusion criteria were the availability of pre- and post-intervention health-related quality of life measures (HRQoL) and data on costs. HRQoL, costs, and cost-effectiveness of treatment were the main outcome measures. Studies (n = 24) focused on treatment of symptomatic fibroids (n = 8), treatment of heavy menstrual bleeding (n = 10), various surgical techniques (n = 5) and the effect of various indications for hysterectomy (n = 2). Follow-up periods varied from 4 months to over 10 years. SF/RAND-36 or EQ-5D measures and societal cost perspective were most commonly used. Only 11 studies used individual patient data. HRQoL following hysterectomy was generally good but costs were high. The cost-effectiveness depended on indication, age, and duration of follow-up. The cost-effectiveness of hysterectomy has been surprisingly poorly studied. Conclusions are difficult to draw due to different study designs, indications, follow-up times, and HRQoL instruments used. Rates of hysterectomy have declined less than expected with the introduction of new treatment modalities. Costs of surgery are high. Laparoscopic hysterectomy seems to be the least cost-effective, although further data from original patient cohorts with long-term follow-up are needed.

Regional and temporal variation in hysterectomy rates and surgical routes for benign diseases in the Netherlands

OBJECTIVE

To provide descriptive statistics on hysterectomy for benign gynecological conditions in the Netherlands and to analyze regional and temporal variations in hysterectomy rates and surgical routes.

DESIGN

Retrospective cohort study.

SETTING

Dutch hospitals.

POPULATION

All women with a hysterectomy for benign gynecological conditions in the Netherlands in 1995-2005.

METHODS

This study is based on an analysis of the Dutch registry of hospital admissions for 1995-2005.

MAIN OUTCOME MEASURES

The age-adjusted hysterectomy rate and age- and diagnosis-adjusted proportion of vaginal hysterectomies for each Dutch healthcare region and time period.

RESULTS

The average annual crude hysterectomy rate for benign disease only, was 17.2 per 10,000 women of all ages. The vaginal route was chosen for 50.8% of the patients. During the study period, the number of hysterectomies for bleeding disorders declined almost 25%. Among 27 Dutch healthcare regions, the age-adjusted hysterectomy rates for bleeding disorders and pelvic organ prolapse varied 2.2- and 2.3-fold, respectively. The average annual age- and diagnosis-adjusted proportion of vaginal hysterectomies varied from 43.4 to 63.8%. The regional differences with regard to rate and proportion declined slightly over time.

CONCLUSIONS

The Netherlands is among the countries with the lowest hysterectomy rates and the highest proportion of vaginal hysterectomies. The regional differences indicate that a further decrease in the hysterectomy rates and an increase in the proportion of vaginal hysterectomies are possible.