Frederick R. Jelovsek MD
Laparoscopic vaginal assisted hysterectomy (LAVH) is a popular
form of hysterectomy when it can replace the need for an
abdominal hysterectomy with a procedure that offers much faster
recovery. Recovery from a vaginal hysterectomy is 2-4 weeks while
that from an abdominal procedure is 4-6 weeks. If all else is
equal (costs, risks) then LAVH should replace many of the
abdominal procedures.
Unfortunately LAVH takes longer than an abdominal hysterectomy
and thus the costs as far as operating room and anesthesia time
are greater. Most patients don't have to directly pay these
increased costs because their insurers do. Physicians are
sometimes hesitant to perform more expensive procedures because
insurers keep track of financial profiles for each physician and
physicians who are more expensive run the risk of not having
contracts renewed.
Some risks seem to be higher with LAVH. Injuries to the urinary
tract including the bladder and the ureter (tube connecting the
kidney to the bladder) can happen with any hysterectomy. Recently
a report, Tamussino KE, Lang PEJ, Breinl E: Ureteral
complications with operative gynecologic laparoscopy. Am J
Obstet Gynecol 1998;178:967-70 from Austria discussed the
rate of ureteral injury, a fairly serious complication usually
requiring further surgery. Normally the rate of ureteral injury
in abdominal hysterectomies is 1-2%. In this study, the injury
rate was 4.3%. There have been other reports that show the same rates
and some that show lower rates of injury. Most physicians agree that urinary tract injury
is higher with LAVH.
The question remains as to whether the higher injury
rate and cost of LAVH is high enough to affect its use or its frequency of recommendation. The
important issue is for women to know the different risks involved
so they can make more informed decisions.
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