HYSTERECTOMY AT AMINU KANO TEACHING HOSPITAL KANO, NIGERIA: A 2 YEAR REVIEW

BACKGROUND : Hysterectomy is the most frequently performed major gynaecological operation worldwide. Globally, over 1.2million women undergo this surgery annually. This has led to a major controversy that hysterectomies are being performed for unnecessary reasons. OBJECTIVES : To determine the prevalence and outcome of hysterectomies in Aminu Kano Teaching Hospital . METHODOLOGY : It was a retrospective study of the hysterectomies done at Aminu st Kano Teaching Hospital, between 1 Jan 2015 st and 31 Dec 2016. RESULTS : The prevalence of hysterectomy was 18.18%. The mean age at hysterectomy was 48.38 + 10.7yrs. The rate of hysterectomy was highest amongst grand multiparous women, the mean parity was 5.9 + 3.3. Symptomatic uterine fibroid was the leading indication for hysterectomy accounting for 29.8%. Most of the hysterectomies were performed via the abdominal route. The ratio of abdominal to vaginal approach was 4.9:1. The most common complication was haemorrhage. Two out of the 47 patients died giving a mortality rate of 4.3%. The average duration of surgery was between 1 and 2 hours (81.5%). The average estimated blood loss was less than 500mls. The histological diagnosis corresponds with the preoperative diagnosis in 72.7% of cases. CONCLUSION : The rate of hysterectomy in this study was high, the outcome was good with low mortality rate. Effective medical and conservative management for benign conditions of the uterus should always be considered and hysterectomy should only be


INTRODUCTION
Hysterectomy is the surgical removal of the 1 uterus.It is indeed the most frequently performed major gynaecological operation 2 the world over.Rates are highest in the industrialized world with an incidence of 42/100,000, 143/100,000 and 236/100,000 in 3 the UK, USA and Germany respectively .Globally, over 1.2million women can expect 3 to undergo this form of surgery annually.One in five women will experience the operation at 3 some point in their lives.In Africa and Nigeria in particular, there are a lot of misconceptions regarding hysterectomy which make it relatively unacceptable to our women; these misconceptions include loss of sex drive and reincarnation without the 4 uterusa.Incidences of 5.1%, 10.7% and 7.8% were reported in Kano, Gombe and Accra 5,6,7 respectively .Although hysterectomy is the treatment for most gynaecologic malignancies, the vast majority of hysterectomies are performed for 8 benign gynaecological conditions.The leading indication in most studies is symptomatic uterine fibroid.Other indications include dysfunctional uterine bleeding, uterovaginal prolapse, endometrial hyperplasia, endometriosis, adenomyosis, cervical intraepithelial neoplasia, chronic pelvic pain and reproductive system cancers such as uterine, cervical, ovarian and endometrial cancers.The data was analyzed using Microsoft excel.Quantitative variables were described using mean and standard deviation.Qualitative variables were presented as percentages in tables, charts and pictograms.

RESULTS
During the study period, 385 major gynaecological surgeries were performed and 70 of these were hysterectomies.The prevalence of hysterectomy was found to be 18.18%.Fourty seven case notes were retrieved giving a retrieval rate of 67.14%.
The mean age at hysterectomy was found to be 48.38 + 10.7yrs.The age range was between 25 and 78yrs.The peak incidence was amongst those between 40 and 49yrs (Table 1).The rate of hysterectomy was found to be highest amongst grand multiparous women, the mean parity was 5.9 + 3.3 (Table 1).Symptomatic uterine fibroid was the leading indication for hysterectomy in Aminu Kano Teaching Hospital and it accounted for 29.8% (Figure 1).

FIGURE 1: INDICATIONS FOR HYSTERECTOMY
was the commonest indication accounting for 12.7%.The most frequent obstetric complication leading to hysterectomy was ruptured uterus constituting 60%, primary postpartum haemorrhage and Couvelaire uterus accounted for 20% each.Most of the hysterectomies were done as elective procedures (87.2%) and mainly via the abdominal route (83%).The ratio of abdominal to vaginal approach was 4.9:1.Total abdominal hysterectomy and bilateral salpingo-oophorectomy was the most commonly performed type of hysterectomy (57.4%).Laparoscopic forms of the procedure are not done in AKTH.All the vaginal hysterectomies were performed by consultants.Six out of the 7 subtotal abdominal hysterectomies were performed by senior registrars.Most of the patients (62.2%) were discharged within 7 days.Majority of the patients (77.8%) who stayed for > 11days were cancer patients who had TAH + BSO (Figure 2) Twenty-four out of the 47 patients had complications giving a complication rate of 51%.The most common complication was haemorrhage, 33.30 % (Figure 3).Two out of the 47 patients died giving a mortality rate of 4.3% and both were obstetric patients.The average duration of surgery was between 1 and 2 hours (81.5%).All the cases that lasted for more than 2hrs were complicated cases and performed by the consultants.In all the obstetric cases, blood loss was more than 1 liter.However, the average estimated blood loss was less than 500mls.Blood loss was  higher via the abdominal surgeries, all the patients who lost more than 1 liter of blood had abdominal hysterectomy (Figure 4).In general, most of the complications occur while performing hysterectomy for obstetrics reasons (Figure 5).The histological diagnosis corresponds with the preoperative diagnosis in 72.7% of cases (Figure 6).The commonest diagnosis was leiomyoma.Multiple histopathological findings were observed in 22.7%.

DISCUSSIONS
The prevalence of hysterectomy in this study was 18.18%, this is lower than 25% reported 13 by Usman et al in Nguru and three times 5 higher than 5.1% reported by ZD Ahmed in Aminu Kano Teaching Hospital.This can be attributed to an increase in awareness of our women and positive change in attitude towards health seeking behavior hence making the procedure more acceptable.Also more cancer patients are now presenting with operable disease.The previous study in Kano excluded obstetric indications.
The mean age at hysterectomy was 48.38 + 10.7yrs.This is similar to 49.9 + 11.3yrs higher than 45.7 + 11yrsreported in Gombe .
The mean parity in this study was 5.9 + 3.3.This is comparable to 5.5 + 3.7yrs reported by Maresh MJ in India at 12.5% .This could be accounted for by the obstetric indications included in this study and also the rising contribution of malignancies to the prevalence of hysterectomy.Primary haemorrhage and anaemia were the commonest complications accounting for 33.3% each.This is similar to the findings of T h e p r o c e d u r e c a n a l s o b e d o n e prophylactically against reproductive tract cancers especially in those with a strong family history such as breast cancer with 9 BRCA1 or 2 mutations.The most commonly performed hysterectomy

FIG 2 :
FIG 2: LENGTH OF HOSPITAL STAY VS TYPE OF HYSTERECTOMY

13 14 15 Usman,FIG 6 :
FIG 6: HISTOPATHOLOGICAL FINDINGS The aim of this study is therefore to determine the current data regarding the indications and complications of hysterectomy in Aminu Kano Teaching Hospital, and compare it with previous studies at the same center.
of their target organ.Mean age of onset of menopause in those who underwent hysterectomy is 3.7yrs earlier than average, 10 even when the ovaries are preserved.

Ibom Medical Journal Vol.11 No.2 August, 2018 FIG 4: BLOOD LOSS VS ROUTE OF SURGERY FIG 5: COMPLICATION VS INDICATION Hysterectomy at Aminu Kano Teaching Hospital Kano, Nigeria: A 2 Year Review multiparas
at 61.7% and least among the nulliparas at 8.5%.Common indications in the nulliparas being uterine fibroid and malignancies.This is similar to 62.1% The mean parity in this study was 5.9 + 3.3.This is comparable to 5.5 + 3.7years reported However, none of the vaginal hysterectomies was performed by a senior registrar.This shows underexposure of residents-in-training in the art of vaginal hysterectomy.This is 18 same as the finding of Onah HE in Enugu.Duration of hospital stay was variable in the study.Eighty percent of the patients were discharged within 10 days of surgery and only 8.5% spent less than 5 days.This is contrary to 69% hospital stay of less than 5days reported 7 by Adanu in Ghana .The complication rate in this study was 51%.This is twice that reported by Usman at 26% in Nguru and is 4 times that reported by 5reported by ZD Ahmed .Ilorin and 4:1 reported by Onah in Enugu .Laparoscopic forms of the procedure are not yet commonly done in Nigeria because very few gynaecologists have acquired the skill and also due to lack of therapeutic laparoscopies.However there are some private facilities that offer laparoscopically assisted hysterectomy During the study period, 72.3% and 27.7% of the hysterectomies were performed by consultants and senior registrars respectively.This is comparable to 78.6 and 21.4 reported 5 by ZD Ahmed .