Indications and Practice of Hysterectomies at the Gynecology-Obstetrics Department of the Pikine National Hospital Center in the Suburbs of Dakar (PNHC)

Hysterectomy, which consists of surgical removal of the uterus, is commonly practiced in treating benign or malignant lesions of the uterus and its annexes, as well as uterine rupture, which has become rare in Northern countries [1]. Its surgical approach has evolved significantly during the 70s-80s in favor of the vaginal route with Dargent's team and the development of the laparoscopic approach, whose availability remains very limited in sub-Saharan Africa [2]. Its practice in Gynecology in Senegal, as in other African countries, remains poorly documented despite its routine performance. In order to update the data concerning its practice, we conducted this work with the objectives of studying hysterectomy practice in a hospital in the Dakar suburbs, describing its epidemiological aspects, analyzing its indications and surgical methods, and describing its complications.

This is a retrospective and descriptive study of hysterectomy cases performed at the Gynecology-Obstetrics department of the Pikine National Hospital Center over a 5-year period (from January 1, 2018, to December 31, 2022). The study included any woman who underwent a hysterectomy during the study period. Women with incomplete records were not included in the study. Data were collected from patient records and analyzed using SPSS 2019 software (IBM Statistics SPSS Version 26). Graphs were obtained using Microsoft Office Excel Professional Plus 2021. Quantitative variables are described in terms of frequency, mean, median (surrounded by its interquartile range), standard deviation and extremes, and qualitative variables are described in terms of frequency (absolute frequency) and percentage (relative frequency) of reported data.

• Epidemiological aspects 

During the study period, we performed 183 hysterectomies out of a total of 7,500 gynecological-obstetric surgical procedures, representing a frequency of 2.4%. The mean age of patients was 47.99±10.42 years with a median of 47 years and extremes of 19 and 86 years. The 40-49 age group was the most represented with 45.9% (n=84). They came mainly from peripheral regions (65.03%) compared to 34.9% from Dakar and were married in 85.8% of cases (n=157). The mean parity was 3.7±2.77 with a median of 4 and extremes of 0 and 12. Nulliparous women were a minority with a rate of 15.8%. Medical history was dominated by hypertension and diabetes, present in 13.6% (n=25) and 6.01% (n=11) of cases respectively, and surgical history was dominated by cesarean section and myomectomy with 10.9% and 7.1% of cases respectively. 

• Clinical aspects 

Outside of emergency contexts, consultation reasons were dominated by pelvic pain (45.3%; n=83), metrorrhagia (28.4%; n=52), and menometrorrhagia (10.9%; n=20), while almost all emergency-admitted patients presented with hemorrhage occurring in the third trimester of pregnancy, during labor, or in the postpartum period. Regarding scheduled surgery, the main diagnoses were uterine fibroids and genital prolapse for benign pathologies, and endometrial cancer and suspicious ovarian tumors for malignant pathologies. In emergency cases, the pathologies found were mainly obstetric complications such as uterine rupture and retroplacental hematoma (Table 1). 

Table 1: Distribution of patients according to hysterectomy indications (N=183). 

• Operative data 

In the majority of cases, hysterectomy was performed as scheduled surgery with a rate of 84%, while 15.8% of cases were performed in emergency contexts. It was total in 89.1% of cases and subtotal in 10.9% of cases. Preservation of adnexa was performed in 55.7% of cases. In more than half of cases (63.1%), general anesthesia was used. This was mainly for cases involving malignant pathology, laparoscopy, or emergency contexts. The preferred surgical approach was laparotomy with a rate of 67.7% (n=124). Laparoscopy and vaginal approaches represented 23.5% (n=43) and 8.7% (n=16) respectively. Among the 43 patients who underwent laparoscopy, conversion to open surgery was necessary in 12 patients (27.9%). This laparoscopic conversion was justified by the need for cytoreductive surgery or lombo-aortic lymph node dissection in 9 cases of endometrial cancer and 2 cases of ovarian cancer. We also noted one case of conversion due to a large fibroid uterus. In patients operated on through the vaginal route, no uterine reduction procedure was performed. Among the procedures associated with hysterectomy, lymphadenectomy was the most common, followed by complementary procedures for prolapse repair and tumor cytoreduction. 

During the intervention, 5 patients (2.7%) experienced operative complications, and in post-operative follow-up, 3 patients (1.6%) presented complications (Table 2). 

Table 2: Complications of hysterectomies at the National Hospital Center of Pikine. 

The average length of hospitalization was 4.4±3.8 days with a median of 3 days and extremes of 1 and 27 days. Generally, patients were hospitalized for 3-4 days after the intervention. There were no deaths.

In our study, we noted a hysterectomy rate of 2.4% of surgical activities with 84.7% of cases performed as scheduled operations versus 15.3% performed in emergency contexts. The patient profile was that of a woman in her forties or fifties, multiparous, consulting for pelvic pain, metrorrhagia, or a vulvar mass. The main indications were uterine fibroids and genital prolapse for benign pathologies, endometrial or ovarian cancer for malignant ones, and pregnancy or postpartum hemorrhage for emergency hysterectomies. The main surgical approach was laparotomy followed by laparoscopy with a 27.9% conversion rate. Total hysterectomy was performed in most cases, but subtotal hysterectomy was more common in emergency contexts, and preservation of annexes was almost systematic in non-menopausal women. The main intraoperative complications involved the urinary system and digestive tract, while hemorrhages dominated postoperative complications. Our results are comparable to those found in other African studies such as those by Ndiaye [3] and Meka [4], who found similar ages. According to Subtil's study [5], the risk of undergoing hysterectomy at age 40 is estimated at 4.5% in France and 12.6% in the United States. At age 50, this risk increases to 12% in France and 23.8% in the United States. At age 70, this risk is 18.7% in France and 34.2% in the United States. Multiparous women dominate all series with average parity varying from 2.05 to 5.7 [6,7]. The predominance of uterine fibroids in hysterectomy indications is worldwide, with rates of 40 to 86% in different African series [8,9], but also in France where Debodinance [10] found a frequency of 66.7%. In 2009, according to the American College of Obstetricians and Gynecologists (ACOG) report [11], uterine fibroids represented 40.7% of hysterectomy indications in the United States. This rate is explained by its frequency in women over 30 years (30 to 50%) but also by the predisposition of the black race to this pathology. Laparotomy remains the predominant approach in most African countries [6,9], but some like Gabon and Morocco are beginning to reverse the trend in favor of the vaginal approach [7,12]. However, in Western countries, vaginal and laparoscopic approaches have overtaken laparotomy [10].

Unlike our series, there is currently renewed interest in subtotal hysterectomy in certain countries where cervical cancer screening is more rigorous. In France [13], for example, subtotal hysterectomy increased from 3-4% in 2002 to 8.5% in 2011, while in Denmark [14], this figure reaches 22%. In California [15], in 1994, 6.9% of hysterectomies were subtotal, but this rate rose to 20.8% in 2003. The main intraoperative complications described in the literature are similar to ours, primarily hemorrhagic complications which are the most frequent, followed by ureteral or bladder injuries.

The practice of hysterectomy remains common in our regions in both Gynecology and Obstetrics where it remains life-saving. The predominance of uterine fibroids in the indications partly explains the choice of laparotomy. The upgrading of technical facilities with the acquisition of morcellators could expand the indications for laparoscopy.

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