Hysterectomy: Which route for which patient?
The vaginal route—with or without laparoscopic assistance—is often preferable to laparotomy, but much less common.
IN THIS ARTICLE
- Editorial We are at the tipping point
KARRAM: What about supracervical hysterectomy? The only time I have performed one was at the time of a cesareanhysterectomy because blood loss was significant and dissection of the cervix could have led to more morbidity. What are the indications for this procedure?
HERZOG: It is unclear whether there are any definitive indications for supracervical hysterectomy. A number of benefits have been proposed, such as better support and improved sexual function. Some of the perceived benefits have been supported by nonrandomized trials, but critical analysis of the randomized data has failed to support most of these contentions.8,9 However, the procedure can be a valuable intervention to decrease critical blood loss intraoperatively, as you point out, or to simplify complicated pelvic surgery in selected cases, such as postpartum hemorrhage, advanced endometriosis, ovarian cancer debulking (when the cervix is not involved), or significant bleeding in patients who object to transfusion on ethical or religious grounds.
FALCONE: There are clear contraindications to supracervical hysterectomy, namely the presence of a malignant or premalignant condition of the uterine corpus or cervix, but no indications, except perhaps for an unstable patient undergoing hysterectomy in whom you want to finish quickly. None of the randomized clinical trials have shown supracervical hysterectomy to be superior to total hysterectomy. The randomized trials involved the abdominal route; the time to complete a laparoscopic supracervical hysterectomy is less than for a laparoscopic total hysterectomy.
Nevertheless, many patients ask for the procedure. After I present the risks and benefits, I leave the choice up to them. Of course, it is important to explain that total hysterectomy implies removal of the cervix and not the ovaries.
LEVY: In rare cases of immunocompromised patients or women with widely disseminated intraperitoneal carcinoma, one could make an argument for avoiding entry into the vagina to reduce infectious risk, speed healing, or avoid tumor seeding. Otherwise, there is absolutely no evidence to support an indication for supracervical hysterectomy.
Does leaving the cervix affect long-term function?
The residual cervix can become the site of later neoplasia or disease.
HERZOG: Supracervical hysterectomy can be associated with several problems with longterm implications. One is the potential for cervical intraepithelial neoplasia. Another concern relates to bleeding from a portion of active endometrium at the top of the endocervical canal. Rarer problems include the development of endometriosis or invasive cancer in the residual cervix. These potential drawbacks need to be strongly considered and included in patient counseling.
KARRAM: One study followed 67 patients for 66 months after supracervical hysterectomy; trachelectomy was ultimately required in 22.8% of patients.10
The $64,0000 question: Remove the ovaries?
Overall, the decision should be made case by case.
KARRAM: Should routine oophorectomy be performed at the time of hysterectomy in postmenopausal women to decrease the potential for ovarian cancer later in life?
HERZOG: This is a very important question. Conventional thinking used to be that, for women over the age of 45, and certainly for women older than 50, ovarian removal should be strongly considered to reduce the risk of cancer of the ovary or fallopian tubes at a later date. Studies focusing on the number of ovarian cancer cases possibly prevented with routine oophorectomy at the time of hysterectomy reinforced this concept. One single-institution study showed that more than 60 cases of ovarian cancer would have been prevented over a 14-year period if ovaries were routinely removed in women older than 40 undergoing hysterectomy. By extrapolation, that would result in more than 1,000 cases prevented annually in the United States.11
Recent data refute the rationale for routine oophorectomy. One study that used statistical modeling with Markov decision analysis to determine life expectancy concluded that, at least until the age of 65, women are best served with ovarian conservation if their risk of developing ovarian cancer is average or less.12 Researchers found that women who underwent oophorectomy before age 55 experienced 8.6% excess mortality by age 80. The validity of certain assumptions used to construct this model has been challenged; nevertheless, this cogent study certainly challenges previous concepts regarding agebased routine prophylactic oophorectomy. Until further study results are reported, it is important to counsel women who are considering having their ovaries removed about the potential risks and benefits. Furthermore, these decisions must be made on a case-by-case basis, with special deliberation given to women at any increased risk for breast or ovarian cancer.
What route is preferred when fibroids are present?
Assuming hysterectomy is the optimal treatment, the vaginal route is feasible.
KARRAM: Uterine fibroids are still the No. 1 indication for hysterectomy. Are minimally invasive laparoscopic procedures with morcellation techniques the best way to manage these women?
