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

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References

Long-term outcomes: the downside

For a mean of 66 months (range: 4 to 7 years), Okaro et al8 followed 70 patients undergoing laparoscopic supracervical hysterectomy by a single, highly skilled laparoscopic surgeon.

Their findings point out the downside of cervical preservation. Although all patients had the endocervical canal and transition zone cored out, over 24% reported symptoms related to the cervical stump—and all required further surgery. Further, cyclic vaginal bleeding occurred in 11% of women.

One patient developed cervical intraepithelial neoplasia. Dyspareunia and pelvic pain were significant complaints in 19% of the patients. (These women were more likely to have had hysterectomy for endometriosis.) Sixteen of the 17 patients with cervical complaints required trachelectomy within the follow-up time period.

“How empty is theory in the presence of fact!”
Mark Twain, A Connecticut Yankee in King Arthur’s Court

Practice recommendations

We, as clinicians, must accumulate evidence from basic science as well as clinical research, put it all together, and make recommendations based on these data. The data, tell us, in fact, that there is no difference in sexual dysfunction, pelvic floor support, or return to normal activity levels when the cervix is retained, and no evidence to support an advantage to supracervical hysterectomy.

My recommendation is for vaginal hysterectomy when possible. The theoretical advantages of retention of the cervix have driven many clinicians to abandon the vaginal approach in favor of laparoscopic supracervical hysterectomy; no data support this theory.

While not the focus of this article, ample data tell us that the vaginal approach, when technically feasible, is less invasive and carries fewer risks for our patients than laparoscopic or abdominal hysterectomy, and permits excellent access for support of the pelvic floor. I do think that patients who truly believe that their sex lives will be ruined after total hysterectomy or that they will do dramatically better if the cervix remains, may experience this self-fulfilling prophecy.

What I tell patients. I carefully review all the facts with patients in helping them select the appropriate surgical procedure.

I tell patients:

  • That overwhelming evidence suggests that sexual function improves in the vast majority of women after hysterectomy, whether or not the cervix is left.
  • That there is a real possibility that cyclic bleeding may occur after supracervical hysterectomy, even when the residual endocervical tissue is cored or coagulated. I stress this point to all women who elect hysterectomy.
  • That randomized trials demonstrate a significant incidence of reoperation for persistent bleeding.
The author serves on the Speakers Bureaus for Barr, Berlex, and Wyeth-Ayerst.

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