Tropical Medicine & Surgery

Health Related Quality of Life after Hysterectomy Performed for Benign Conditions in Tertiary Hospitals, Rwanda

Corneille Killy Ntihabose^1* and Bonaventure Twahirwa^{2 1}Department of Clinical and Public Health sciences, Rwanda Biomedical Center, Kigali, Rwanda
²Department of Medicine and Health Sciences, University of Rwanda, Gicumbi, Rwanda
^*Correspondence: Corneille Killy Ntihabose, Department of Clinical and Public Health sciences, Rwanda Biomedical Center, Kigali, Rwanda, Tel: 250 788 600 997, Email:

Received: 23-Jun-2021 Published: 14-Jul-2021

Introduction

Hysterectomy is one of the most common major operation performed by gynecologist worldwide, second only to cesarean section. It can be performed using vaginal, abdominal or laparoscopic approaches and the choice of approach is influenced by many factors. Over 600,000 hysterectomies are performed in the United States annually [1]. In almost 90% of women having a hysterectomy, the surgery is carried out for benign conditions, particularly uterine fibroids, which is the most common indication for the procedure. Benign gynecological conditions can cause a diversity of physical symptoms and have a negative impact on quality of life. Hence hysterectomy provides alleviation of any of these disturbing complaints and consequently can improve the quality of life. According to the definition established by the World Health Organization (WHO), quality of life is an individual’s perception of life in the context of value systems and the culture in which they live and relating to their expectations, concerns, goals and standards [2]. This outcome variable is a broad term, dealing with environment-based quality of life and Health-Related Quality of Life (HRQoL).

Nowadays, it is known that the functional impact on patients’ lives of medical interventions is important in predicting the need for services, and that it is inadequate to measure outcome of medical intervention considering morbidity and mortality. In many studies reporting on surgical procedures, outcome variables focus on patient morbidity such as hospital stay, surgical complications, operation time, and recurrence rate. However, from the patient’s perspective, outcome measures related to quality of life and health status such as symptom resolution, satisfaction and return to normal activities are also important as the traditional surgical outcomes [3]. These HRQoL variables measured concurrently and prospectively, contribute additional features to mortality and morbidity measures. HRQoL involves several areas that cover the generic dimensions necessary to any HRQoL assessment, which are social, physical, emotional functioning and perceptions of overall quality of life corresponding to a disorder or its particulars treatment modalities. For particular investigations, however, the assessment of other aspects of HRQoL may be important. These aspects include: sexual functioning, psychological, productivity, symptoms, sleep disturbance and pain [4]. The specific aspects of HRQoL assessed in any study will vary depending on the particular health condition and research subject under investigation. Quality of life is a necessary outcome variable in medical research and in surgery for benign gynecological conditions. Although surgery can have positive and negative effects, most women reported a reduction in physical complaints and an increase in health perceptions after hysterectomy.

Due to the rate of complications after hysterectomy and the significant number of surgeries that do not relieve discomfort, nonsurgical therapy may be more appropriate initially and when nonsurgical management fails to succeed, hysterectomy can be performed to treat benign conditions, hopefully relieving such discomfort and enhancing the quality of life. In Rwanda, showed that hysterectomy was the most common gynaecologic surgery performed (32.1%). There is lack of information regarding HRQoL after hysterectomy in Rwanda. Therefore, it is important to assess whether hysterectomy improves HRQoL in our setting [5]. As HRQoL refers to an individual’s total wellbeing, having a proper understanding of this concept by nursing and medical staff allows them to provide accurate information to the patient during postoperative counselling, thereby enhancing the appropriateness of treatment and care. Hence the aim of this study was to assess the health-related quality of life in women after hysterectomy performed for benign conditions in our setting and to determine the associations of HRQoL with patient characteristics, indications of hysterectomy for benign conditions, the types of hysterectomy for benign conditions and the rate of hysterectomy among Obstetrics and Gynaecological (OBGYN) surgeries performed in women.

Materials and Methods

This was a prospective longitudinal study conducted from the underwent hysterectomy for benign gynecological conditions at Rwanda Military Hospital (RMH), Kigali University Teaching Hospital (CHUK) and Butare University Teaching Hospital (CHUB). These are the national public referral hospitals providing tertiary care services in Rwanda where most surgeries are performed [6]. All patients who consulted OBGYN department at national public referral hospitals were evaluated either by an OBGYN consultant or an OBGYN senior resident, the diagnosis and management plan were established. A convenience sample of 110 women who underwent hysterectomy for benign conditions as the treatment option were recruited to be participants in the study. All participants who had hysterectomy for benign gynecological conditions based on the final histopathology report were included and the exclusion criteriawas the loss to follow up. Data was collected using a questionnaire. The questionnaire comprised of two parts: the first part was used to assess the demographic and clinical characteristics of participants and the second part was used to assess the HRQoL. Clinical characteristics of participants were collected by either principal investigator or trained nurse in perioperative period from patient’s interview and medical records using pre-established questionnaire and the HRQoL data were collected by principal investigator or trained nurse using the SF-36 questionnaire prior to surgery [7]. During the follow up at 3 months postoperative, the health-related quality of life data was collected by principal investigator; patients were interviewed on telephone and completed the SF-36 questionnaire.

The SF-36 is a 36-items questionnaire which measures eight health subscales: bodily pain; general health; physical functioning; role limitations due to physical health problems; social functioning; energy/fatigue; role limitations due to emotional problems and emotional wellbeing. The SF-36 was built to represent two major subscales of health. The Mental Component Summary (MCS) and the Physical Component Summary (PCS). The summary components comprise 35 of the 36 items in the form; 14 in the MCS and 21 in the PCS. For each subscale, item scores are coded, summed and converted into a scale from 0 (worst health) to 100 (best health).These 36 items were adapted from the tool completed by patients participating in the medical outcomes study in different systems providing health care. The SF-36 Kinyarwanda version was used [8].

Data entry was done using Epidata 3.1 then exported to IBM SPSS statistics version 25 for analysis. Descriptive statistics such as means and percentages provided a general description of sample characteristics. Data distribution was evaluated using Shapiro-Wilk test. Because the data were skewed, Kruskal-Wallis and Mann-Whitney U tests were used to analyze the associations between overall QoL and patient characteristics. To assess the HRQoL quality of life, Wilcoxon signed rank test was used to analyze the associations of HRQoL score before and 3months after surgery. Associations were considered to be statistically significant at a p-value<0.05. All women provided written informed consent before the study. Ethical approval was obtained from the institutional review board of college of medicine and health sciences at university of Rwanda before starting the study. Approval from research ethics committees of CHUK, CHUB and RMH were offered before data collection. Intergovernmentalism and politics of autonomization of local government in Nigeria [9].

The concept of inter governmentalism or better still inter governmental relations refers to all the complex and inter dependent relations among various spheres of government as well as the co-ordination of public polices among national, provincial and local government through programme reporting requirements, grants-in-aid, the planning and budgeting process and information communication among officials. Implicit here is that, every tier of government has been identified and their financial relation is clearly noted. This is because finance is very pertinent to combat the developing challenges affecting all the tiers of government and local government in particular. Intergovernmental relations as interaction that take place among the different levels of government exist within a state. Also, it comprises of all the permutation and combinations of relations among the units of government in a federal system.

On the financial relations to local government, the position and functions of an auditor general for the local government of a state is detrimental to the struggle for granting autonomy to local government by state and the federal governments and; distort thorough active participation of the people and their traditional institutions in local initiatives. In Nigeria, the practice of intergovernmental relations is streamed lined in to central-state-local, central-state, state-local and inter local relations; and fiscal relations is central. According to the constitution of the federal republic of Nigeria section 7 as amended; states that the house of assembly of a state shall make provisions for statutory allocation of public revenue to local government councils within the state. Also, the state wields greater level of control over the financial resources of the local government. The office of auditor general which is answerable to the state governor is adequately responsible to the control of the monies accruable the local governments within the state. This depicts that the attainment for the autonomy of local governments is a serious issue to be granted on a platter of gold [10].

Results

A total of 4211 obstetrical and gynecological surgeries were performed in study period, Hysterectomy was the second most common procedure after cesarean delivery (6.7%) (Figure 1).

Figure 1: Obstetrics and gynecologic surgeries in tertiary hospitals.

Participants were premenopausal (64.1%). CBHI was the most health insurance (89.1%). Most women were Protestant (45.7%) and married (56.5%). The majority of the patients undergoing hysterectomy were multiparous with (63.7%) of women having parity of four or more as shown in Table 1.

Table 1: Demographics and characteristics of participants.

This implies possible delay in health care seeking issues granted behavior among less educated women until they have developed more severe symptoms compared to the more educated women who have more access to health education.

Of the 110 patients enrolled 92 patients were analyzed, 11 patients were excluded for malignancy confirmed by histopathology. The mean age of participants was 51 ± 9 years.

In Nigeria, the traditional institutions in the local governmented practice of intergovernmental relations is streamed lined in to central-state-local, central-state, state-local and inter local relations; and fiscal relations is central. According to the constitution of the federal republic of Nigeria section 7 as amended; states that the house of assembly of a state.

The average length of hospital stay was 6 ± 4 days. The most common indication for hysterectomy was fibroids (52.2%). Most of the hysterectomies (76.1%) were performed using abdominal approach. Uterine prolapse was an indication for hysterectomy performed at advanced age (60 ± 8) (Table 2).

Table 2: Number, age, length of stay, hysterectomy indication according to the type of procedure.

Table 3: Quality of life before and after hysterectomy.

All domains showed significant improvement in HRQoL scores after hysterectomy (p<0.001). The PCS improved from 28.8 to 61.3 (p<0.001) and the MCS improved from 35.8 to 67.0 (p<0.001) (Table 3).

Discussion

Hysterectomy performed for benign conditions is usually aimed at improving the quality of life for the woman by alleviating the symptoms, resuming function and alleviating the woman’s fear of progress to a malignant state. The results of this study have shown a significant improvement in all eight subscales of HRQoL measured before and at three months post hysterectomy for benign conditions. These results are similar to the findings from Taiwan and Malaysia that used a different tool and demonstrated post-surgery improvement of QoL after 8 and 12 weeks respectively with other studies that measured the HRQoL at 6 months and beyond post-surgery have also shown significantly improved and maintained HRQoL afterwards.

Whether a woman with a gynecologic issue still desires for fertility is one of the drivers in decision making for surgical management and hence it is common for gynecologist to be reluctant in deciding hysterectomy for a woman in reproductive age or who has not completed their childbearing. Even though there was no statistically significance in pre-surgery scores between premenopausal and post-menopausal women, the former was significantly more likely to have better perception of their HRQoL after hysterectomy even though their natural ability to conceive was lost. This is contrary to the results from Iran which showed a low quality of life after hysterectomy particularly for social and psychological aspects in premenopausal women but this study also used a different tool to evaluate the HRQoL [11].

The pre-surgery median difference between women who attended at least secondary education and women who had primary or no education was lost when hysterectomy was performed. This implies possible delay in health care seeking behavior among less educated women until they have developed more severe symptoms compared to the more educated women who have more access to health education and are more knowledgeable about symptoms that prompt for early consultation. Similar findings were observed in India that have shown higher mean scores on MCS as a result of higher education but different from Korea where women with lower education had otherwise higher level of sexual satisfaction after surgery. During surgical practice, surgeons attempt to minimize all preventable complications of surgery. Among our study participants, complications were associated with longer hospital stay but none of the surgical complications has shown significant association with HRQoL. This could demonstrate adequate patients’ counseling and education on complications of surgery in addition to its proper management while keeping the patients’ satisfaction.

The type of surgical approach chosen to perform hysterectomy has been documented to have a remarkable impact on long-term HRQoL, length of hospital stay and complications. While systematic reviews have shown fewer blood loss, shorter hospital stay and better scores of HRQoL compared to TAH laparoscopic and vaginal hysterectomies are not yet routinely integrated into practice by local medical staff in Rwanda and hence, it was difficult to compare the effect of different modalities given their small numbers in our cohort. As the country has engaged the community in improving maternal health through the help of community health workers, there is a need to address other women’s issues by education and utilization of health services before the quality of life is compromised. Hysterectomy should be offered when the medical management has failed to alleviate the patient’s complaint regardless of the age and menopausal status but patient autonomy and fertility desire should be fully discussed.

The strengths of our study are the use of the SF-36, the most common used and validated tool of HRQoL worldwide. It was also available in Kinyarwanda that improved communication with participants. In addition, this questionnaire has been used in other studies, permitting our findings of being compared with those of other studies. It is important to have culturally appropriate and validated methods of assessment as results from other settings may not be able to be extrapolated to Rwanda. Another strength of this study is its prospective follow up design, which decreases the probability of recall bias. Patients were requested to remember only the previous four weeks when they filled the SF-36. Missing data and loss to follow up were also minimised. The limitations of our study are that SF-36 instrument does not make examination on disease-specific gynaecologic quality of life such as defecation complaints, urogenital distress, menstrual symptoms, depression, sexual problems or speed of recovery. In addition, there were difficulties in patient enrolment and retention in order to get adequate sample size and to minimise the loss to follow up. There were limited alternative modalities to the transabdominal approach to make valid comparisons.

The results of this study measured the fundamental HRQoL after hysterectomy performed for benign conditions in Rwanda.

Considering these results, disease specific quality of life studies could be considered to evaluate the effect of hysterectomy in our settings. Furthermore, long term follow up could be studied as complications evolve over time. Quality of life monitoring for a health system is important to insure that elective surgical interventions have a sustained positive impact on patients. This study represents the first to examine quality of life after hysterectomy and further study is necessary to insure appropriate care for our patients.

Conclusion

The strengths of our study are the use of the SF-36, the most common used and validated tool of HRQoL worldwide. It was also available in Kinyarwanda that improved communication with participants. In addition, this questionnaire has been used in other studies, permitting our findings of being compared with those of other studies. It is important to have culturally appropriate and validated methods of assessment as results from other settings may not be able to be extrapolated to Rwanda. Another strength of this study is its prospective follow up design, which decreases the probability of recall bias. Patients were requested to remember only the previous four weeks when they filled the SF-36. Missing data and loss to follow up were also minimised. The limitations of our study are that SF-36 instrument does not make examination on disease-specific gynaecologic quality of life such as defecation complaints, urogenital distress, menstrual symptoms, depression, sexual problems or speed of recovery. In addition, there were difficulties in patient enrolment and retention in order to get adequate sample size and to minimise the loss to follow up. There were limited alternative modalities to the transabdominal approach to make valid comparisons.

The results of this study measured the fundamental HRQoL after hysterectomy performed for benign conditions in Rwanda.

Considering these results, disease specific quality of life studies could be considered to evaluate the effect of hysterectomy in our settings. Furthermore, long term follow up could be studied as complications evolve over time. Quality of life monitoring for a health system is important to insure that elective surgical interventions have a sustained positive impact on patients. This study represents the first to examine quality of life after hysterectomy and further study is necessary to insure appropriate care for our patients.

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