Hysterectomy for benign uterine conditions: Cost evaluation, post procedural quality of life and pelvic organ function.

Abstract

OBJECTIVE: The Objective was to assess costing, quality of life and pelvic organ function in women undergoing total abdominal hysterectomy (TAH), non-descent vaginal hysterectomy (ND VH) and total laparoscopic hysterectomy (TLH) for benign uterine indications. METHODS: A randomized controlled trial* was done in two public sector hospitals. Eligible participants were patients requiring hysterectomy for non-malignant uterine causes. The exclusion criteria were; uterus>14 weeks, previous pelvic surgery, those requiring incontinence surgery or pelvic floor surgery, any medical illness which cautioned/contraindicated laparoscopic surgery. A societal perspective with micro-costing for direct hospital costs was used to calculate costs. Time to recover and the difference in utility scores (EQ-5D-3L questionnaire) were used to assess quality of life. Pelvic organ function was assessed using validated ICIQ-VS, ICIQ-FLUTS questionnaires and an interviewer based questionnaire for bowel symptoms. RESULTS: The operative time was significantly more in TLH (93 (80-111) compared to TAH 45 (36.5-60) and ND VH 50 (35-65) (p<0.01). The post-operative hospital stay was shorter in the TLH 2 (1-3) compared to TAH 3 (2-3) and NDVH 3 (2-3). The total cost [(interquartile range), number] of TAH was USD 338 [(310-408), n=49] versus USD 334 [(297-414), 11=49] for NDVH and USD 412 [(364-460), 11=49] for TLH (p<O.001). There Was no difference in median time (interquartile range) to recover among TAH, NDVH and TLH which was 35 (30-45), 32 (24.5-60) and 30 (25.5-45) days respectively (p=0.37). The area under the curves (AUC) at the end of 6-months for TAH, NDVH and TLH were 8.63, 9.97 and 13.84 respectively. There was no significant difference among the three different routes in terms of vaginal symptoms score (VSS), sexual symptoms score (SSS), urinary flow symptoms, urinary voiding symptoms, urinary incontinence symptoms and bowel symptoms at 6-months and 1-year. The incremental cost-effectiveness ratio (ICER) for TLH was USD 12/day. NDVH showed a net benefit as both costs and median effect were superior to TAH. The incremental cost utility ratio (ICUR) for TLH and NDVH were 12 and 38 USD/QALY. The ICUR for TLH compared to NDVH was USD 3/per QALY. The net monetary benefit (NMB) compared to TAH was USD 4897 and USD 1264 for TLH and NDVH respectively. CONCLUSION: An insignificant marginal difference was seen among the three routes when considering time to recover, QALYs and pelvic organ function. However, a cost-effectiveness approach using ICER, ICUR and NMB showed that alternate routes, NDVH and TLH to be superior to the conventional TAH. KEYWORDS: 'Hysterectomy, cost, quality of life, pelvic organ function, randomized controlled trial