Clinical Review

Hysterectomy: Total versus supracervical surgery

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Once considered a routine part of hysterectomy, removal of the cervix is being questioned in light of postoperative sexual function. Here, a look at both sides of the issue.


 

References

Key points
  • An “internal orgasm” may be linked to sensory input from the cervix. Therefore, removal of the cervix may inhibit sexual satisfaction.
  • In a study evaluating the sexual functioning of women prior to and following supracervical, or “subtotal,” hysterectomy, about half the women reported improved sexual function, one-third reported little change, and one-fifth noted deterioration.
  • The more interested and sexually active a woman is preoperatively, the more likely she is to report satisfactory sexual function postoperatively.

Concerns about postoperative sexuality often top the list of questions when a woman contemplates hysterectomy.1 Unfortunately, data regarding the impact of hysterectomy on sexual function are conflicting. Further, as Grimes points out, the literature fails to elucidate the role of the cervix in sexual response.2 Thus, it is difficult to advise women which procedure is better: a total or supracervical (“subtotal”) hysterectomy. The decision must be individualized following a thorough discussion with the patient.

One factor hampering scientific evaluation of the subject is the complex and ambiguous nature of the physiologic and psychologic aspects of sexuality. Preoperative medical conditions, emotional well-being, and/or the pathologic process necessitating the hysterectomy itself may contribute to both pre- and postoperative sexual functioning, as may the nature of a woman’s personal relationships and her support system. Therefore, it is no surprise that various studies have shown improvement, stability, and deterioration in sexuality following hysterectomy.1

Technique and other factors

With approximately 600,000 procedures performed annually, hysterectomy is one of the most common operations in the United States. Indications for the procedure constitute a broad spectrum of benign and malignant gynecologic disease.

Most gynecologists in practice today were taught to remove the cervix at the time of hysterectomy. To do otherwise was a sign of surgical naiveté. Recently, however, employing a uniform and inflexible approach has been questioned. As new surgical devices and advances in minimally invasive technology make it possible to perform subtotal hysterectomy safely and expediently, the debate over the fate of the benign cervix has been rekindled. Not only are new data emerging, but patients themselves are beginning to question the physical, physiologic, and psychologic sequelae of various operative techniques and participating, to a greater extent, in the formation of a surgical plan.

For the subtotal procedure, only the fundus is amputated from the cervix.

The total procedure. First, the uterus is separated from its surrounding and supporting tissues. The ligaments within the broad ligament, as well as the ovarian and uterine vessels, are clamped, divided, and ligated at their uterine attachments. Once the dissection has reached the level of the vaginal fornices, the bladder is mobilized anteriorly, the rectosigmoid colon posteriorly, and the ureters laterally with regard to the plane of resection. The uterus and cervix are then separated from their attachments to the vagina.

The subtotal procedure. For this technique, the uterine fundus is approached as described in the total hysterectomy. However, after the uterine blood supply is controlled, only the uterine fundus is amputated from the cervix. This procedure allows for varying amounts of the proximal cervix to be removed, depending on the extent of dissection. This is determined by the indications for the hysterectomy and the intraoperative anatomic findings. (A classification system in this regard has been proposed by Munro and Parker.3) The remaining cervical stump is cauterized and its edges coapted. At the conclusion of the procedure, the cervical stump appears similar to a vaginal cuff.

In my practice, after ligating the uterine vasculature, I remove a small portion of parametrial tissue at the level of the cervical isthmus to ensure the removal of all endometrial tissue. If some of it remains, menstrual flow may continue following the procedure.

While many gynecologic surgeons amputate the fundus from the cervix by transecting the tissue in a flat plane, I find that this hinders stump closure, especially when trying to coapt the tissue. Instead, I prefer to “core out” the proximal endocervical tissue. This technique—often described as a “reverse cone”—has several advantages. It effectively ensures excision of all endometrial tissue. In addition, some researchers have hypothesized that excision and cauterization of the endocervical canal can reduce the risk of adenocarcinomas of the cervical stump. Lastly, removal of this tissue allows for reapproximation of the wound edges without tension.

Complications and physiologic considerations

All surgical procedures carry some risk of adverse sequelae. In the case of hysterectomy, sites of potential injury include the bladder, rectosigmoid colon, and ureters. In fact, Harris found complication rates of 1% to 2% associated with the bladder, 0.25% to 0.4% for the bowel, and 0.2% for the ureters.4

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