AUDIT OF PATHWAY TO HYSTERECTOMY DR TIMMY KOWLESSAR (SpR) MS A. ARYA (Consultant) Obstetrics & Gynaecology Dep’t QEH King’s Lynn 13th March 2013

AIMS To determine whether there is a documented discussion of conservative options of treatment, instead of major surgery. To determine proportion of patients opting for surgery and reasons for discontinuing conservative management. To determine whether patients are given adequate information on surgical risks at consenting.

METHOD Retrospective analysis of 25 case notes of patients who have had a hysterectomy for benign indications between March – December 2012.

RESULTS - AGE

INDICATION FOR HYSTERECTOMY

Type of hysterectomy

Indication for hysterectomy

Was there a documented discussion of alternatives to surgical treatment? 60-69yo, prolapse G3 cystocoele, G1 uterine descent Seen and consented by Middle Grade.

Did the patient agree for trial of expectant management?

Indication for hysterectomy in patients DECLINING conservative measures (15 / 24)

Indication for hysterectomy in patients who initially tried conservative measures (9/ 24) Prolapse - 60-69 yrs PFE’s, pessaries x 9 years Repeated UTIs and vaginal infections. Vag hyst 70-79 yrs Pessary x 8 months Patient requested surgical mx. Vag hyst

Indication for hysterectomy in patients who initially tried conservative measures (9/ 24) Menorrhagia - All 40-49 yrs All because of failed conservative mx (not side effects or pt’s request) Duration : 6 – 53 months Mean 16.5 months Median 9 months

Consent, Information Leaflet

Discussion of surgical risks – TAH RCOG Consent Advice Guideline – Hysterectomy for Benign Conditions Serious Risks Urinary tract injury, +/- bladder dysfunction Bowel injury Haemorrhage +/- bld transfusion Thromboembolism Return to theatre Pelvic abscess / infection Frequent risks Wound infection, dehiscence Numbness, burning at scar UTI, frequency Ovarian failure

Surgical risks – TAH (n=8)

Discussion of surgical risks – VH RCOG Consent Advice Guideline – Vaginal Surgery for Prolapse Serious Risks Urinary tract injury Bladder dysfunction (new or existing) Bowel injury Haemorrhage + bld transfusion Thromboembolism Return to theatre Pelvic abscess / infection Recurrence Frequent risks PV bleeding Wound infection UTI, frequency, retention Postop pain, dyspareunia

Surgical risks – VH (n=8)

Discussion of surgical risks – Operative Laparoscopy Infection Haemorrhage Thromboembolism Bowel injury Urinary tract injury, voiding dysfunction Conversion to open procedure Return to theatre

Surgical risks – Lap (n=9)

Surgical risks – Blood transfusion, additional procedures – documented on consent form

Summary of results 25 women, 24 offered non-surgical alternatives. 15 / 24 (63%) preferred surgery. 9 / 24 (37%) opting for conservative mx – 2 prolapse, 7 menorrhagia. Menorrhagia – opted for surgery after failed medical mx, median duration of treatment – 9 months. Most consent forms filled by consultant. Consistently poor documentation of possibility of blood transfusion and whether an information leaflet was provided. Some significant surgical and postoperative risks not documented on consent form.

Discussion Small study, n=25. Significant proportion of laparoscopic procedures. No women in 20-30’s had hysterectomy for menorrhagia – successful use of conservative measures. More patients presenting with prolapse opted for surgery. Patients with menorrhagia requested hysterectomy after failed medical management. Good documentation of risks at consenting, but significant omissions!!

RECOMMENDATIONS Info leaflets should be readily available in each clinic room. Following discussion of options, give info leaflets to women requesting surgery, with contact numbers if they change their minds. Important to follow guidelines – menorrhagia, prolapse. Prolapse – appointment with nurse specialist to further discuss use of pessaries, before deciding on surgery.

RECOMMENDATIONS Methods to improve compliance with consent guidelines Use of printed info sheets, transcribed onto consent form. Stickers. Procedure-specific consent forms…

Advantages HYSTERECTOMY Word doc can be modified, legible, comprehensive Uniformity Saves time HYSTERECTOMY

RECOMMENDATIONS Re-audit planned after agreed changes implemented.