RANCHO MIRAGE, CALIF. — Renewed interest in performing supracervical rather than total hysterectomies in the past 2 decades means some of these women will need trachelectomy or cervical stump removal at some point in the future.
To better understand the indications for trachelectomy and its potential complications, Wesley Hilger, M.D., and his associates at the Mayo Clinic, Scottsdale (Ariz.) reviewed 310 trachelectomies performed at the clinic from 1974 to 2003.
Prolapse was the predominant reason for trachelectomy, particularly in the 202 patients who underwent vaginal trachelectomy. A pelvic mass was the most common reason for abdominal trachelectomy, he said at the annual meeting of the Society of Gynecologic Surgeons.
The study found low rates of complications, especially in the vaginal trachelectomy. “When only trachelectomy was performed,” without concomitant procedures, “complications were almost nonexistent,” he said.
Half of the trachelectomies in the series were performed in the first of the 3 decades studied. Historically, 95% of hysterectomies performed before the 1950s were supracervical procedures, due to a lack of antibiotics and anesthetics, Dr. Hilger noted. Starting in the 1950s, surgeons shifted to total hysterectomies, which the new drugs made safer to perform. By the late 1970s and 1980s, however, some began to question whether retaining the cervix might help maintain sexual and bladder function, prevent prolapse, and reduce surgical morbidity. The rate of supracervical hysterectomies increased from 0.7% to 2% of U.S. hysterectomies between 1990 and 1997.
“Whether one approach is superior to another is still debated. What we know is that if someone undergoes a supracervical hysterectomy, the cervix may need to be removed in the future. If the supracervical hysterectomy rates continue to rise, we may see an increase in the number of trachelectomies in the future,” he said.
The 108 patients who underwent abdominal trachelectomy were younger than the vaginal trachelectomy group (58 vs. 67 years), lost more blood during surgery (606 cc vs. 193 cc), and were hospitalized longer (8 days vs. 6 days). The time between hysterectomy and trachelectomy was significantly shorter in the abdominal trachelectomy group—19 years, compared with 30 years after vaginal trachelectomy.
The third most common indication (after prolapse or pelvic mass) was cervical dysplasia or cancer. The interval between hysterectomy and trachelectomy for dysplasia or cancer averaged 21 years, compared with a 31-year interval for trachelectomies performed due to prolapse.
Because so much time passes between the surgeries, physicians who perform supracervical hysterectomies are unlikely to be the ones performing trachelectomies in the same patients, Dr. Hilger noted.
Bleeding was the indication for trachelectomy in 9% of patients. “Patients who are contemplating a supracervical hysterectomy should be counseled that cyclic or even noncyclic bleeding may persist and may necessitate another procedure,” said Dr. Stephen B. Young, who discussed the study following Dr. Hilger's presentation.
Patients also should be counseled about a risk for developing cancer in the cervical stump after supracervical hysterectomy, added Dr. Young of the University of Massachusetts, Worcester.
Histologic analysis of the cervical stumps removed in the study found that 5% had cervical cancer, 6% had dysplasia, 1% had adenocarcinoma, 1% had fibroids, 32% were normal, 53% had cervicitis that was not considered clinically significant, and 2% had other findings.
No postoperative complications were seen in 80% of vaginal trachelectomies and 57% of abdominal procedures. Infections developed in 7% of the vaginal group and 13% of the abdominal group, and urinary retention in 6% and 8% of vaginal and abdominal trachelectomies, respectively.