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Subtotal vs total hysterectomy: Does the evidence support saving the cervix?

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Research does not support claims that preservation of the cervix reduces sexual dysfunction, incontinence, or surgical complications.

“There is something fascinating about science. One gets such wholesale returns of conjecture out of such a trifling investment of fact.”
Mark Twain, Life on the Mississippi


 

References

KEY POINTS
  • Sexual function is not improved more with supracervical than with total hysterectomy.
  • Operative morbidity for supracervical and total hysterectomy are similar.
  • Pelvic-floor support and urinary incontinence do not seem to be improved with the supracervical approach.
  • Cyclic bleeding occurs in 5% to 20% of women after supracervical hysterectomy.
  • Reoperation rates for symptoms related to the retained cervix are significant—over 20% in the hands of highly skilled surgeons.
Thanks to the advent of minimally invasive, organ-preserving treatments such as endometrial ablation, progesterone-containing intrauterine delivery systems, and uterine fibroid embolization, today’s patients suffer less morbidity and enjoy better outcomes for a number of procedures. To take advantage of the potential for improved patient care, we try to use every new technology for every suitable candidate.

Hysterectomy is an obvious target. The number of hysterectomies performed has not declined substantially since these technologies were introduced, and persists at more than 550,000 per year in the United States. It is still the most widely performed major gynecological procedure.

Technological advances have made possible the use of laparoscopy to facilitate removal of the uterus without a major abdominal incision, with its inherent hazards. Many surgeons, seeking to make the most of new technology, have revisited laparoscopic subtotal hysterectomy, advocating preservation of the cervix to reduce surgical complications, sexual dysfunction, and pelvic-floor defects after hysterectomy.

New data, however—much of it released only in the last 12 to 18 months—tell us there is no difference in sexual function, pelvic floor support, or return to normal activities when the cervix is retained. What’s more, leaving the cervix in place puts the patient at greater risk of reoperation related to hysterectomy.

THEORY

Improved sexual function

EVIDENCE

Recent prospective analyses using validated measures of female sexual function have failed to demonstrate any advantage for supracervical hysterectomy.

Scientific study of sexual function is difficult at best. Many factors influence sexual behavior, and all must be considered when analyzing the effects of hysterectomy. To clearly understand the impact of hysterectomy on female sexual function, prospective studies in which women serve as their own controls provide the best quality evidence. That said, the contention that supracervical hysterectomy results in better sexual function than total hysterectomy stems from the research of a single group, which in 1983 retrospectively compared coital frequency, dyspareunia, libido, and orgasm after “supravaginal uterine amputation” with total hysterectomy.1,2

Simple hysterectomy causes minimal disruption of Frankenhauser’s plexus of autonomic nerves.

They theorized that supracervical operation preserves Frankenhauser’s plexus of autonomic nerves, resulting in better sexual function. However, careful anatomic assessment of the nerve content in the ligaments supporting the uterus has since demonstrated that the rich nerve supply to the uterosacral and cardinal ligaments occurs in the lateral two thirds of these structures. Simple hysterectomy causes minimal disruption of these autonomic nerves, ganglia, and extensions of the inferior hypogastric plexus.3

Thakar et al,4 in a pivotal multicenter, double-blind, randomized trial conducted in the United Kingdom, randomized 279 patients with benign disease to supracervical or total hysterectomy and followed them for 12 months. Surgical technique was standardized and the endocervix was coagulated in all patients.

The 2 groups were similar in measures of sexual function, including frequency of intercourse, orgasm, and rating of relationship with partner.

The Danish Hysterectomy Group5 randomized 319 patients with benign disease to total abdominal hysterectomy or subtotal abdominal hysterectomy, of whom 276 completed validated mailed questionnaires preoperatively, and at 2, 6, and 12 months postoperatively.

There was no change in sexual satisfaction in either group from their prehysterectomy levels. Overall quality of life improved significantly in both groups, in both mental and physical measures.

Roovers et al,6 in a multicenter, nonrandomized trial—powered well to detect 20% differences—compared vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy (technique chosen by the surgeon).

Of the 379 patients recruited (from 13 teaching and nonteaching hospitals in the Netherlands) who had a male partner, 93% completed a validated questionnaire before and 6 months after surgery.

The questionnaire—used to assess sexual pleasure, activity, and problems—specifically addressed lubrication, orgasm, pain, and arousal on a 5-point scale (“not bothered” to “severely bothered”). Their findings:

  • Sexual pleasure increased significantly in all groups regardless of type of hysterectomy.
  • There was no difference in the incidence of bothersome sexual problems, but a significant number were reported: 43% after vaginal, 41% after subtotal, and 39% after total abdominal hysterectomy (P =.88).
  • New sexual problems were reported in 9 patients (23%) after vaginal hysterectomy, 8 patients (24%) after subtotal hysterectomy, and 12 patients (19%) after total abdominal hysterectomy.
  • There was a nonsignificant trend toward higher prevalence of arousal and lubrication problems after subtotal hysterectomy and total abdominal hysterectomy, compared with vaginal hysterectomy.

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