SAINT LOUIS UNIVERSITY

College of Nursing
Baguio city

JOURNAL

Overview of Current Trends in Hysterectomy

Santiago Domingo; Antonio Pellicer
Authors and Disclosures
Posted: 11/25/2009; Expert Rev of Obstet Gynecol. 2009;4(6):673-685. © 2009 Expert Reviews Ltd.

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Submitted By:
Naulgan, Tzietel Dee C.
SLU-BSNIII
Section N Group No. 1
 Overview of Current Trends in Hysterectomy
Santiago Domingo; Antonio Pellicer
Authors and Disclosures
Posted: 11/25/2009; Expert Rev of Obstet Gynecol. 2009;4(6):673-685. © 2009 Expert Reviews Ltd.
Introduction
Hysterectomy is, after Caesarean delivery, one of the most common surgical techniques performed in women and, together with cholecystectomy and
appendicectomy, is the most frequently performed intra-abdominal surgery. The majority of gynecologic surgeons continue to perform
hysterectomies by means of a laparotomy, while cholecystectomy is almost always performed through laparoscopic surgery. [1] Many women's health
institutions recommend avoiding laparotomy, and advise abdominal hysterectomy (AH) only when the vaginal or laparoscopic route is ruled out.We
may ask ourselves why practice tends to go against this consensus. Vaginal surgery offers great potential in terms of access to the uterus, and fulfils
all the criteria for minimally invasive surgery, as it employs a natural orifice, thereby avoiding an abdominal scar. The vagina becomes a new trocar
port-site, permitting uterine manipulation, pelvis dissection and easy removal of the specimen. Vaginal hysterectomy (VH) is the safest route and has
the best cost–effectiveness ratio, making it the first-choice option in clinical practice. When contraindications or difficulties are expected, vaginal
surgery should be performed with the aid of laparoscopy when necessary or throughout the entire intervention, according to the professional opinion
of the surgeon. Although AH is not currently contraindicated, there are now sufficient surgical resources for it to be relegated to the end of the list of
options. Scientific evidence favors VH and laparoscopic hysterectomy (LH), which have lower complication rates, produce less postoperative pain
and shorter hospital stays, and allow a more rapid return to normal activity, thereby resulting in a better quality of life (QoL). Laparotomy continues
to be the preferred method for hysterectomy in approximately 60–70% of benign uterine processes. Is this a sign of a deficit in surgical skill that is
transmitted from generation to generation of specialists? The hysterectomy rate is showing a slight change in favor of VH rather than LH, although it
is no way near the estimated 80–90% of hysterectomies that could potentially be managed with a minimally invasive approach. Unfortunately, the
decision to adopt the surgical route evidently depends more on the skill of the surgeon than the advantages this technique may have for the patient.In
this review, we intend to assess the options available when considering a hysterectomy and to establish the most appropriate indications for its
recommendation, to consider the alternatives to hysterectomy and to analyze the different surgical techniques and their routes and complications.

Indications for Hysterectomy

There is considerable variation in policy concerning hysterectomy in healthcare centers and gynecological programs. Although hysterectomy rates in
Western countries are diminishing owing to a generally more conservative approach, and this operation is still widely performed. [6] However, rates
differ considerably between countries, ranging from a high of 5.4 per 1000 women in the USA [7] to intermediate rates, such as 3.7 per 1000 in Italy,
to a low of 1.2 per 1000 in Norway. [9] The hysterectomy rate in developing countries is lower. The incidence rate has dropped by approximately 1‰
every decade since 1980; even so, almost 20% of women in these countries will have a hysterectomy by the age of 55 years. The conditions that may
lead to a hysterectomy cause discomfort and inconvenience rather than threaten life. The diversity of symptoms can have an immense influence on a
woman's QoL, affecting aspects of her daily routine, general health and sense of wellbeing. [15] In most women who suffer gynecological disorders,
QoL improves following a hysterectomy. Moreover, this surgery does not tend to produce any psychological disturbances in otherwise
psychologically healthy women. In this way, most women who are undergoing this operation regain a so-called normal life. Menorrhagia is the most
frequent cause for hysterectomy in pre-menopausal women, with myomas and adenomyosis constituting the leading pathologies of the uterus. There
is a 20–25% incidence of uterine fibroid tumor in women of fertile age but, fortunately, these are usually asymptomatic. If a surgical approach is to
be adopted, the reproductive desire of the patient must be taken into account. Thus, a conservative myomectomy should be the first recommendation
in women without children and who are still capable of becoming mothers. If there is no intention of preserving fertility, hysterectomy is a definitive
solution, unless other, more conservative, treatments can be offered, such as the levonorgestrel intrauterine device (LNG-IUD).Another indication for
hysterectomy is pelvic pain, mainly caused by endometriosis and/or adenomyosis. This condition can usually be managed with analgesic drugs (e.g.,
NSAIDS or paracetamol) and anovulatories; however, if necessary, surgery of the adnexa (endometrioma) is indicated. A hysterectomy may be
proposed when more than one pathological circumstance is present. Uterine prolapse is also a common indication for hysterectomy, as it cannot be
managed in a conservative manner. Hysterectomy is recommended unless a uterine-sparing desire is expressed, and accounts for 10% of the global
rate of surgery. Vaginal surgery cannot be avoided when there is a prolapse, although it may be managed laparoscopically. Malignancy and
postpartum hemorrhage are less frequent indications and account for only 10% of the total rate of hysterectomies.

Should Bilateral Salpingo-oophorectomy be Indicated?

Some years ago, it was estimated that 7.1% of future deaths would be prevented by concurrent salpingo-oophorectomy, mainly owing to avoiding the
risk of ovarian cancer. [18] An age limit was set at 45 years old for carrying out this procedure while performing a hysterectomy. However, the
evidence regarding this practice is inconclusive, as many contradictory results have been reported. Indeed, several studies have detected a reduced
risk of ovarian cancer after hysterectomy and without bilateral oophorectomy. [19,20] Current scientific evidence suggests that elective oophorectomy is
not advisable for the majority of women as it may lead to a higher risk of death from cardiovascular disease and hip fracture and a higher incidence of
dementia and Parkinson's disease. Recently, it has been concluded that preserving ovaries until at least the age of 65 years was associated with higher
survival rates.

Cost–Effectiveness of Hysterectomy

Hysterectomy appears to be cost effective when compared with alternative conservative therapies (endometrial resection and ablation and medical
therapy for menorrhagia) in long-term follow-up studies. The relatively high probability of the need for future surgery following a conservative
approach is of great relevance in the decision-making process.Management of such a prevalent surgical procedure can have a transcendental impact
on healthcare systems. The vaginal route is the most cost-effective approach and has been shown to be effective in a variety of indications. The
Society of Pelvic Reconstructive Surgeons estimate a potential saving of US$1,184,000 for every 1000 hysterectomies performed via the vaginal
route and a reduction in complications of approximately 20%, with the subsequential indirect economical benefits (e.g., hospital stay and early work
incorporation).[25] The cost of LH is higher than that of other approaches, mainly owing to the additional cost of the disposable instruments that are
employed.[26,27] However, this is a somewhat superficial interpretation, as it does not take into consideration the recovery of the patient, which is more
rapid with this procedure. One must remember that it is also cost effective to reduce convalescence and, consequently, period of inpatient care.

Surgical Approaches to Hysterectomy: Relevant Factors in Decision Making

Surgeon Skill

Age, parity, uterine size, vaginal anatomy, pelvic mobility and any pelvic disease or previous pelvic surgery are among the most important factors to
take into account when considering a hysterectomy. Yet, an even more important aspect is the quality of the surgeon's training with respect to the
different possible approaches. This is why continuous training programs must be offered to residents and gynecologic surgeons with the intention of
developing effective guidelines for the determination of the route of hysterectomy in every medical center. Many publications confirm that route
indication may change when guidelines are consulted; up to 90% of hysterectomies are performed vaginally when a consensuated guideline is
applied, reversing the abdominal/vaginal procedures to a ratio of 1:11. [28] Each hospital should examine its own AH:VH ratios as a quality-assistant
index. This dramatic change requires a learning curve, and that of the laparoscopic technique is more difficult and longer than that of the vaginal
technique. In 5 years, a VH rate of 95% could be achieved in some centers in the UK, where only 32% of hysterectomies have, until now, been
performed via the vagina. [29] This highlights the strong economic argument for VH in medical centers and confirms that the major determinant of
hysterectomy route is not clinical circumstances but, rather, the professional preparation of the surgeon. Appropriate practice guidelines are needed to
reduce inconsistencies in the indications for AH and VH. Unfortunately, almost all teaching programs focus more on AH rather than VH or LH.

Uterine Size

The ACOG and other researchers assert that VH should be indicated in women with mobile uteri of less than 12-week gestational size (~280 g),
maintaining that the contrary can represent a handicap for surgeons. [2] Randomized studies that compare the advantages, disadvantages and outcomes
of AH and VH for enlarged symptomatic uteri between 200 and 1300 g have clearly demonstrated the advantages of the vaginal route in terms of
operative times, febrile morbidity, less demand for narcotics and reduction of hospital stay. [30] Uterine size reduction is usually the principal problem
confronting surgeons, and morcellation technique skills are a limiting factor. The mechanical difficulties and the higher risk of complications during
morcellation are common contraindications of VH and an indication for abdominal hysterectomy for many gynecologic surgeons not trained in the
technique. Uterine morcellation techniques (e.g., coring, corporeal bisection and wedge morcellation) are safe and facilitate the vaginal removal of a
moderately enlarged uterus without increasing perioperative morbidity. [31–33]

Uterine Mobility

Uterine mobility is another of the relevant factors in determining the route of a hysterectomy. A vaginal route is usually indicated in cases of vaginal
prolapse (stage ≥ 1), a wide vaginal apex and a bimanual pelvic palpation presenting a nonadhered uterus. Occasionally, a pelvic examination under
anesthesia is required prior to determining if vaginal access is possible.

Pathological Condition

Uterine prolapse is one of the most usual indications for hysterectomy. Although a laparoscopic approach is feasible in such circumstances, VH with
a McCall culdoplasty is the standard treatment. Other situations should be attemped vaginally once malignancy has been ruled out, such as cervical
carcinoma in situ or abnormal uterine bleeding. Even if an endometrial carcinoma is detected, the vaginal route may be possible, with a vaginal
adnexectomy being performed if lymph node dissection is not indicated (low risk of endometrial carcinoma). Moreover, in cases of malignancy and
poor patient clinical outlook, a VH should be the first option, as it allows a locoregional anesthesia to be administered. A myomatous uterus is one of
the most controversal indications for VH. Uterus shape is probably more relevant than uterus size, as multiple myoma can be easier to remove than a
single myoma located above the round ligament. An ultrasound scan should assess the exact location of the fibroids and their size. If the clinical
history or pelvic examination indicates possible extrauterine disease or adhesions (e.g., endometrosis, pelvic inflammatory disease, ovarian disease,
previous pelvic surgery or Caesarean delivery), a laparoscopy should be performed. This allows the pelvic pathology to be treated correctly and can
be of assistance in performing or finalizing the hysterectomy. Laparoscopic scoring systems have been designed to document the severity of
extrauterine pathologic conditions.[34]

Nulliparity

Nulliparity usually leads to VH being ruled out, as a general consensus among health professionals. On the other hand, there are no differences
between the complication rates of AH and LH in nulliparous women. [35,36] The lack of cervical descent represents a problem when performing VH.
The main supports of the uterus are the uterosacral and cardinal ligaments. When the vaginal route is chosen, these ligaments are easy to identify and
hold on to, and are the first structures to be dissected, even in nulliparous women. When they are sectioned, the uterus gains mobility, thus making
the procedure easier. Technique Characteristics Three main types of hysterectomy are now used: AH, VH and LH. However, the most important
issue in the approach to these surgeries is not the technique per se, but the guidelines in the clinical decision-making process. The SPRS practice
guidelines comply with recommendations of the ACOG, which indicate that the route of hysterectomy should be based on surgical indication, the
patient's anatomic condition, relevant data, informed patient preference and the surgeon's training and experience. However, in reality, physicians are
expected to adopt evidence-based practice guidelines that are cost effective and defined by outcomes rather than physician preference or experience.
Abdominal Hysterectomy

In benign conditions, AH should be adopted only when pathological circumstances and the patient's characteristics preclude the vaginal and/or
laparoscopic route. The hysterectomy via abdominal route has traditionally been chosen when the uterus was too big (>12 weeks) or the vagina too
narrow, when there was little or no uterus descent and when severe intra-abdominal conditions were suspected owing to previous pelvic surgery
(Caesarean section included), adhesions, endometriosis or adnexal disease. It is essential that all these circumstances are evaluated but, in reality,
many of them have never been sufficiently analyzed. Fortunately, since the arrival of laparoscopic surgery, the majority of these vaginal
contraindications can be resolved with laparoscopy. Thus, previous pelvic surgery or any extrauterine disease (adhesions, adnexal pathology) no
longer pose a problem to less invasive routes. When VH is not possible, LS is preferable to AH, although it involves a higher chance of bladder or
ureter injury, usually related to the learning curve.

Vaginal Hysterectomy

Vaginal hysterectomy should be the standard procedure for removing the uterus in most of the patients. [32,41,42] A significantly faster return to normal
activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) endorse VH
as a preferable option to AH, whenever possible. Surgical morbidity and associated morbidity are much lower with VH than with AH (3.2 and 0.9%
vs 6.2 and 4%, respectively). [43] In a randomized, controlled trial comparing the three methods of hysterectomy, the abdominal technique required an
extra day in hospital and an extra week of convalescence. VH was regarded to be the most cost effective of all three types of surgery. Furthermore,
VH was the best approach for obese patients and elderly patients with comorbidity. Currently, a real ratio of VH/AH varies between 1:3 and 1:4 or
less, depending on the country, but as explained previously, the adequate training of medical teams could turn this ratio around to 1:8–1:15. Previous
pelvis surgery, usually in the form of a Caesarean section, does not preclude the vaginal route. Obviously, in this situation, the major concern is the
risk of injury to the bladder and the difficult entry into the peritoneum through a scarred anterior pouch. An examination under anesthesia and a
diagnostic laparoscopy can help to clarify such doubts surrounding the most appropriate indication for surgery. Vaginal hysterectomy involves two
important and sometimes difficult technical steps: entrance through the peritoneum into the two vaginal cul de sacs and examination of all the uterine
attachments. The performance of bilateral salpingo-oophorectomy and uterus morcellation are further procedures that may need to be performed.
Bilateral salpingo-oophorectomy is usually a contraindication for VH, as it can be technically difficult, especially in postmenopausal women.
However, it can be successful if the correct technique is employed. In order to provide easy access to the infundibulo–pelvic ligament, the round
ligament above the broad ligament must be separately clamped, cut and ligated as far away from the uterus as possible. A specially devised clamp
(e.g., a Sheth's adnexa clamp or similar) is applied above the round ligament stump to include the full length of the infundibulo–pelvic ligament.
Other systems can be employed if anatomical difficulties are present, including the endoloop suture, a modern sealing system. In a prospective study
that evaluated oophorectomies performed during VH, a 97.5% success rate was achieved using these techniques. [47]

Laparoscopic Hysterectomy

The role of LH remains difficult to define, in spite of the extensive scientific evidence available. Its ultimate aim is to reduce the rate of AH rather
than that of VH. Initially, laparoscopy management was devised in order to assist VH in the case of absolute/relative contraindications, such as
adhesion, Caesarean scars, adnexectomy and lymphadenectomy. However, a complete laparoscopic performance of the hysterectomy has evolved
over time. LH shortens hospital stay, induces less postoperative pain and allows quicker recovery, all at the expense of a longer operation time. [51] LH
carries a higher risk of injury to adjacent organs, but may be cost effective, despite higher direct costs, because of the shorter hospital stay and
quicker recovery.One of the most important 'advantages' of the introduction of laparoscopic surgery into gynecology training is that it increases
surgeons' confidence and their vaginal surgery skill, making VH a more feasible option. This has played an important role in reducing the number of
AHs, as many surgeons feel more comfortable removing via the vaginal route. In LH, at least part of the operation is performed laparoscopically. [52]
This method requires a longer learning curve and greater surgical skills than the vaginal and abdominal methods. The rate of hysterectomies
performed laparoscopically is gradually increasing owing to the advantages it affords. It allows a clear view of all pelvic and abdominal structures
and facilitates pelvic disease management (e.g., adhesions and endometriosis). In addition, it can be of assistance in adnexal surgery and in checking
for pelvis hemostasis once surgery has terminated, and it is characterized by less pain and a rapid recovery time.The wide variety of techniques
employed makes it difficult to carry out a relevant comparison of different reports (or even the results of the same study). As the laparoscopic
technique has many particularities, a simple classification has been proposed by which three subcategories are distinguished ( Box 2).[52,54] The
laparoscopic-assisted VH (LAVH) is performed partly laparoscopically and partly vaginally but the laparoscopic component does not involve uterine
vessel ligation. In uterine vessel ligation LH, although the uterine arteries are managed laparoscopically, a part of the operation is performed
vaginally (vaginal suture and colpotomy.). In total LH, the whole operation is performed laparoscopically, thus requiring great endoscopic surgical
skill.

Endometriosis is one of the major indications for LH, as the technique makes it easier to remove peritoneal or adnexal endometriosis implants by
means of different systems (excision, coagulation or vaporization). Endoscopy offers surgeons a magnified view of the pelvis, with close-up images
of the pouch of Douglas, ovarian fossa and visceral and parietal peritoneum that are much clearer than those obtained during a laparotomy. A large
uterus is another indication for laparoscopy, as uterine fibroids are a common relative contraindication for VH. Although vaginal morcellation can be
achieved with the previously mentioned techniques, it also can be performed laparoscopically with modern laparoscopic morcellators. This
management approach can be slow, but it is efficient and safe.

As expected, LH has been extensively analyzed and compared with other techniques. The literature contains four randomized control trials
comparing VH with LH. LH was constantly associated with longer operation times than VH, but with no differences in hospital stay, postoperative
pain sensation or postoperative recovery. In total, 12 randomized, controlled trials compared LH with AH, [3,57–67] and all confirmed the advantages of
the former, describing similar overall complications but less blood loss, fewer transfusions, less pain, shorter hospital stays, lower levels of disability
and better QoL. One of the disadvantages of LH was the longer operating times reported for the endoscopic procedure. [68–70] When endoscopic skills
are adequate, total LH can be quicker, more efficient and associated with less blood loss than LAVH, particularly in nulliparous or obese patients.
Although not strictly necessary, one of the more important steps of this technique is the use of an intrauterine manipulator, which mobilizes the
uterus in all directions to create space in the working field and facilitate dissection and colpotomy. This instrument significantly reduces the operating
time and complication rate (usually vesical and ureteral injury) and permits a more reproducible technique. Uterine manipulators should not be
employed in cases of endometrial malignancy, as it can increase the hypothetical risk of vaginal relapse. The learning curve is also a relevant factor
in LH. This is a difficult aspect to study, and is usually discussed in terms of operation time, conversion and complication rate. The aforementioned
laparoscopic skills of the surgeon determine the length of the curve. The Finnish registry demonstrated that the experience of the surgeon was directly
related to the occurrence of major complications; it highlighted that, after 30 LHs, bladder and ureter injuries were far less frequent. There are no
absolute contraindications for laparoscopy, and relative circumstances are usually related to general anesthesia and hypothetical problems in the
abdomen entry. Morbid obesity (BMI > 30) is often a challenge when establishing the pneumoperitoneum. Previous abdominal scars, especially
midline incisions, increase the risk of abdominal adhesions and can make abdominal entry and surgery difficult, leading to a major incidence of
bowel lesions. In the majority of cases, uterine size is not a contraindication, as modern endoscopic morcellation facilitates the removal of the uterus.
A more transcendental aspect is uterine mobility, as a fixed uterus is a challenge to the laparoscopic approach and to any route.

Robotic Surgery

Robotics is a new step in laparoscopy and LH, and has been implanted in many centers since 2001. It offers all the benefits of the laparoscopic
approach with several key differences: the instruments constitute an articulating wrist that mimics the movements of the human hand, it affords 3D
vision and the usual hand trembling that occurs when performing delicate movements is avoided. The seven degrees of freedom of the articulating
wrist make it easier to work in the deep pelvis, and it performs perfect movements when suturing, excising and reconstructing tissue. Little evidence
concerning robotic hysterectomy has been published to date, but reports that favor this approach are beginning to appear. This approach offers the
patient another minimally invasive option in addition to laparoscopy or VH.

Surgical Complications

The three types of hysterectomy have been compared in terms of complications. In the most recent meta-analysis, [40] urinary tract injury was
significantly higher in LH than AH (odds ratio: 2.61), while no significant differences were found in LH versus VH (odds ratio: 1) or total LH versus
LAVH. No significant difference was observed between other intraoperative visceral injuries (bowel or vascular) as a result of the surgical
approaches.The abdominal approach has constantly been related to a higher incidence of febrile episodes and wound infections. Although no
differences have been reported with respect to blood transfusion, LH has been associated with a smaller drop in hemoglobin and blood loss. As
discussed previously, AH involves the longest hospital stay of all the hysterectomy routes, while VH and LH require similar inpatient convalescence.
When analyzing operation time, the laparoscopic approach is a more time-consuming technique than AH (mean difference: 18 min) and VH (mean
difference: 44 min). The operation time of LAVH was significantly shorter than that of LH (mean difference: 23 min). [40]

Impact on Pelvic Floor Dysfunction

Recent robust studies suggest that significant postoperative morbidity due to pelvic organ dysfunction is not common after total hysterectomy (TH).
When performing a hysterectomy, anatomical relationships are disrupted and the local nerve supply to the pelvic organs (e.g., bladder or rectum) is
damaged, the latter of which is more frequent in radical hysterectomy. Obviously, these complications can alter pelvic organ function and support.
These adverse effects tend to be less serious after sub-TH (STH). In fact, sexual function improves after this intervention, which is why in the 1980s–
1990s the surgical trend moved in this direction. The Maryland Women's Health study, the largest prospective study to date, investigated the effects
of hysterectomy with and without concomitant urinary incontinence repair on incontinence severity. Interestingly, they found that most women with
severe and moderate urinary incontinence before hysterectomy noted an improvement 1 year after surgery and further improvement at 2 years, but
women with no incontinence before hysterectomy had new-onset incontinence 1 year after surgery (17%). Indeed, hysterectomy reduced previous
urge-frequency symptoms, and new symptoms were observed in only 4% of cases at 1-year follow-up. In the face of these contradictory results,
randomized studies comparing TH and STH have concluded that simple hysterectomy does not adversely affect urinary function and may even lead
to improvement. Furthermore, STH has been shown to not confer any benefits over TH in terms of bladder function. There is no evidence that
hysterectomy produces bowel dysfunction or exerts a negative influence on sexual function. Recently, a systematic review of sexuality after
hysterectomy concluded that research in this area was largely retrospective and lacked valid outcome measures. [82] Most studies have shown either no
change or an enhancement of sexuality following hysterectomy. Even when compared with more conservative management (endometrial ablation),
no differences have been found. [83] Conservation of innervation when performing a STH may improve sexual intercourse, but there have been no
reports of a difference in the frequency of intercourse or orgasms when TH and STH are compared. In fact, one study reported a significant increase
in the frequency of intercourse and a decrease in dyspareunia following hysterectomy, the latter of which has been confirmed by more recent
evidence.[80] This suggests that the cervix per se does not play a major role in sexual response. A hysterectomy is one of the most influential factors in
genital prolapse. The incidence of vault prolapse following this operation is substantial, at between 0.2 and 43%. It occurs more frequently when the
vaginal route (10%) is preferred to the abdominal route (2%). Indeed, the former approach is frequently associated with some grade of prolapse. [86]
However, an in-depth analysis reveals that VH per se is not a risk factor for vault prolapse. This condition is normally due to the formation of an
enterocele after a hysterectomy, which begins as a small intestine hernia that progresses to the vagina. A McCall's culdoplasty should always be
performed in these circumstances, as it strengthens the DeLancey level I and avoids this physiopathological mechanism.

Alternatives to Hysterectomy

The indications for hysterectomy discussed are not universally accepted, as other conservative approaches may be considered first. Current
alternatives are so effective that they have had a direct bearing on the negative tendency in hysterectomy rates. Medical treatments can be considered
as a first step in the management of menorrhagia, as they can reduce the growth of uterine volume and stop hypermenorrhea and menstrual bleeding
prior to surgery. However, they tend to be only temporarily effective and often have important side effects. Other more conservative alternatives that
can be offered include endometrial ablation, the progestin intrauterine device, myomectomy and uterine embolization.
Medical Approaches

Sexual steroids are widely used for controlling uterine bleeding. Oral estro–progestin combinations or even progestin alone exert great control over
menorrhagia and dysmenorrhea, but their efficacy is short rather than long term. Gonadotropin-releasing hormone agonists can lead to amenorrhea
and a diminishment of myoma size in 35–65% of cases within 3 months of treatment, thereby creating a menopause status in the short term.
However, the significant menopause symptoms (i.e., vasomotor effect and negative impact on bone density) and the gradual recurrent growth of
myomas associated with cessation of treatment rule out the long-term use of these drug. Mifepristone, an antiprogesterone agent, has proved its
usefulness in controlling the symptoms of leiomyoma. [90] Several studies of high-dose mifepristone have reported a reduction of leiomyoma volume
of 26–74%, which is comparable to that achieved with analogs. Although amenorrhea is a common adverse effect, no negative impact on bone
mineral density has been demonstrated, while the presence of de novo endometrial hyperplasia and elevation of transaminase levels are the most
frequent side effects.[91] Further studies are required for this agent to be included in the medical algorithm treatment of menorrhagia.

Myomectomy

Myomectomy is one of the most effective options for when aiming to spare fertility. Although a surgical approach, the risks it represents are similar
to those of hysterectomy.[92] It is a safe and effective treatment of menorrhagia, with a resolution rate that has reached 80%. [93] The recurrence rate of
leiomyoma is estimated at 11% 1 year after surgery and up to 80% after 8 years. The reoperation rate is lower, at 6.7% at 5 years and 16% at 18
years, with a definite hysterectomy rate of approximately 10%.One of the risks that must be assumed with this approach is an unexpected
hysterectomy owing to surgical complications, in particular, intraoperative bleeding.In the past, myomectomy has usually been performed
abdominally but, nowadays, a laparoscopy/hysteroscopy is feasible. Owing to the complex nature of dissection and suturing, a high grade of surgical
skill is required.Hysteroscopy constitutes another endoscopic method of myoma management and has a good outcome when these are submucous.
Myomas are the cause of approximately 10% of uterine bleeding and pain, and are successfully removed in a high percentage of cases with this
technique (85–95%).As with abdominal/laparoscopic myomectomy, secondary surgery is required in approximately 5–15% of cases. Effectiveness
decreases over time, with a success rate of 76% at 5 years follow-up, and other procedures, such as endometrial ablation, are often necessary. [98]

Endometrial Ablation

Several new technologies may reduce the need for hysterectomy and, among them, endometrial ablation is currently one of the most employed. We
can distinguish between two methods of this technology: selective and nonselective.Selective methods include endometrial resection with a
urological type resectoscope, a rollerball or laser ablation. All require previous endometrial preparation in order to diminish the thickness of the
endometrium, usually with a gonadotropin-releasing hormone agonist. Observational studies and randomized trials have found no differences
between the clinical outcomes of the different techniques employed. Generally, these outcomes are positive, with high satisfaction rates (~75%) and
QoL measures and a positive balance in post-treatment hemoglobins being reported. This approach has been compared with hysterectomy in
randomized trials, yielding better outcomes in operation time, hospital stay and direct costs. These treatments are known as first-generation
endometrial ablation techniques, which distinguishes them from the wide range of new methods for removing or destroying the endometrium more
rapidly and safely.They do not depend heavily on the skill of the surgeon, contrary to selective methods, which explains the positive development of
these new technologies. Many nonselective ablation techniques have been developed. In short, a thermal probe is introduced inside the uterine cavity
in order to raise the endocavity temperature sufficiently during a short interval (10–15 min) during which the endometrial tissue is destroyed. This
procedure can also be performed with a frozen probe. A recently updated Cochrane review on endometrial-destruction techniques concluded that
efficacy and user satisfaction with the first- and second-generation endometrial destruction techniques are similar. It is expected that, in the future,
they will be used in day-out protocols with a similar efficacy to that of selective endometrial procedures and at a lower cost.However, hysterectomy
produces significantly better patient-satisfaction rates than endometrial ablation. How can this be explained? One of the problems of ablation is the
need for further surgical intervention with time. It is estimated that 15% of cases undergo a second endometrial ablation within 5 years, while 20% of
patients eventually undergo a hysterectomy, both of which increase the direct cost of the process, thus calling into question the real efficacy of the
procedure.

Levonorgestrel-releasing Intrauterine Device

The LNG-IUD is one of the most important advances in the conservative management of menorrhagia. Its simplicity, efficacy and patient security
offer a very attractive alternative to patients with hypermenorrhea, with or without myomas or adenomyosis. This device releases levonorgestrel over
a period of 5 years through a rate-limiting membrane (20 µg/day). In addition, it is probably the best reversible contraception method, with a Pearl
index of 0.11. Its mechanism works by inducing an endometrial atrophy, with an average reduction in menstrual blood loss of 90% over 6 months, [110]
and with 20–50% of patients experiencing amenorrhea in the first 2 years after insertion. Its benefits on QoL are evident and its outcome has been
compared to that of hysterectomy, producing the same improvement in health-related QoL at 12-month follow-up at less than a third of the cost. [110]
Meta-analysis of trials comparing LNG-IUD with first-generation endometrial ablation techniques have shown that satisfaction rates are similar,
despite the former producing a smaller reduction of blood loss and lower amenorrhea rate. [112] In this way, LNG-IUD is probably the best of the
conservative approaches to treating menorrhagia. In spite of the aforementioned evidence, medical therapy (e.g., progestins and anovulatories) is
sometimes preferred as an economical option in the treatment of menorrhagia. However, the costs associated with long-term use of oral therapy can
be surprisingly high, while LNG-IUD has been shown to incur the lowest cost among available therapies. That said, in many countries, oral
progestins continue to be the most frequently prescribed medical therapy for menorrhagia.

Uterine Artery Embolization

Transcatheter bilateral uterine artery embolization is a relatively new conservative treatment of symptomatic myoma but one that is rapidly becoming
common.The procedure is performed under local anesthesia or sedation, and an angiography catheter is guided percutaneously via the patient's
femoral artery into the ipsilateral or contralateral uterine artery. Particles of polyvinyl alcohol 300–500 µm are injected in boluses until blood flow
has ceased. The catheter is then withdrawn from the uterine artery, and the procedure is then repeated with the contralateral uterine artery.
Randomized trials regarding the efficacy of uterine artery embolization are yet to be reported. Reduction of uterine and myoma size is one of the
easiest and most objective measures of confirming the efficacy of this treatment using ultrasound scan or MRI. However, menorrhagia and its
symptoms, which are clinical, are the most relevant aspects to evaluate, and these have a resolution rate of almost 90% at short-term follow-up. [116]
One randomized trial demonstrated this method to be the most economic strategy for women with symptomatic myoma.

Ultrasound-focused Therapy

The rationale of ultrasound-focused therapy is based on ultrasound-energy penetration of a defined tissue (in our case, a myoma), which produces a
structural and functional alteration of that tissue. This targeted treatment causes irreversible cell damage, leading to coagulative necrosis due to
thermal and nonthermal effects produced in the exposed area. The depth between the skin and the targeted tissue is a determining aspect: when too
deep, the ultrasound energy attenuates exponentially. [120] For correct and effective use, an endoscopic probe or interstitial applicator is necessary,
usually with a MRI/ultrasound-guided system. Although few trials with this method have been reported until now, the results are encouraging.
Shrinkage of the myoma volume is often low, with a rate of 12–48% being reported, but early clinical improvement (e.g., pain or heavy bleeding) is
significant. Long-term results are necessary in order to discern its real cost–effectiveness. [121]

REACTION:

Hysterectomy is one of the most prevalent surgeries worldwide. Nine out of every ten hysterectomies are performed for noncancerous
conditions that are not life threatening but have a negative impact on quality of life. Indication policy must be revised as new
treatments become available. Menorrhagia is the primary indication and is not always a response to an anatomical disease like my
patient who experienced this type of symptoms before she was diagnosed with myome. New and improved alternatives are
increasingly employed for this indication and are responsible for the fall in the rate of hysterectomies performed in the last decade.
Up-to-date knowledge of the procedure and its possible routes and their outcomes should form part of all clinical decision-making
processes if optimum short- and long-term results, an improvement in the patient's quality of life, and cost–effectiveness are to be
achieved. Vaginal hysterectomy fulfils all these requirements and, when combined with the laparoscopic approach, represents the best
option among possible routes. This would be very helpful not only to my patient but to everyone.

Relevance :
a.) To nursing profession:The article is relevant not only to the persons who are affected and involved but it is also relevant to
the nursing profession, why ? this is because we should have a plan of care and action regarding this condition, we should
know what to say to our patients explaining this type of procedure, everyone in the health care team should work as a group
and learning from this journal would actually give us an idea on what our patients are undergoing it would be even awkward
if our patients ask question and we don’t have anything in mind to answer this would now question our function as a nurse,
even at a very young age as a student nurse we should be really updated on this type of surgical procedures not only to
increase our grades and as a requirement but it would also help us in our function as a student nurse, this would also increase
our awareness about obese individuals that are gradually increasing this might be the effect of technology that people are now
becoming too dependent on machines and this would also be an effect of generation changes as years goes by the no. of
diseases and complications are increasinga aswell, lots of diseases are branching out from one another, stating that
Hysterectomy does not modify the risk of mortality from cardiovascular disease or cancer but should be adequately evaluated
in cases of bilateral oophorectomy, which is a considerably common situation among women. Many surgeons remove the
ovaries in order to avoid a hypothetical ovarian cancer without giving sufficient thought to the impact it may have on the
woman's health or its cost–effectiveness, our role now as a student nurse is to atleast inform our patients that the surgery that
they are about to under take has a considerable side effects or negative impact to their health, maybe the surgery would
prolong their life but in the later part if we also consider other procedures this would even be better. Maybe our role as a
student nurse is simple but it helps a lot in our patients if we try to do our tasks.

b.) To nursing research:This would act as a spring board for further study, not only would it be helpful to the patient but the
same is true with the students specially those undertaking research subjects it would be used also as a future reference of
studies related to the topic. This journal would also add up informations to the students to consider the pro’s and cons of
research and add up aditional informations to them. After reading from it they might as well share it to their fellow students
and even their love ones. By participating in research projects, nurses become leaders in their own departments by working to
improve nursing practice and patient care. Nursing researchers can mentor a clinical nurse through the entire research
process, as needed for us nursing students to be more efficient. This reserch would be also a training ground for us as future
nurses that while we are still learning we can add this up in our knowledge to be applied to our patient care in the area.
 c.) To nursing practice: This is relevant to the nursing practice for us to inform our patients about this procedure and educate
our patients aswell about the complications When a hysterectomy is decided upon, there are many circumstances that should
be taken into account. Patient opinion and surgeon integrity are transcendental. Many women are not even informed of which
method of hysterectomy they are about to undergo when admitted to hospital. Patients should be informed of the
characteristics of the different routes and their benefits and disadvantages. Clinicians should ask themselves if the skills and
technology available in a medical center are made clear when counseling patients. Worryingly, some decisions are made
during surgery without the scientific evidence to back them up, such as the performing of a 'free' bilateral adnexectomy. This
subject deserves extensive discussion elsewhere, as it is not within the scope of the present review. We should be conscious
of the great negative impact that hysterectomy can have on QoL. Moreover, if the ovaries are preserved when a hysterectomy
is performed between the ages of 50 and 54 years, there is a 10% increase in the probability of surviving to the age of 80
years. The 0.5% survival advantage estimated as a result of preventing ovarian cancer is not a convincing enough reason to
choose an abdominal approach. Patients put their trust in medical personnel, and we should make decisions based purely on
the scientific evidence available. For example, an argument for VH is the lack of a need to perform a bilateral salpingo-
oophorectomy, which is known to be more complicated.Apart from openly discussing the three methods of hysterectomy and
their respective indications, the surgeon's skill with respect to each of the three routes must be a factor. If we ask whether
surgeons are frank about their competency in each route, the answer is probably no. Some surgeons remain reluctant to
change their practice patterns, tending to select the abdominal route without considering the feasibility of the vaginal route.
However, if we are to be more rigorous in our clinical decision making, some changes must occur within gynecological
programs. It seems that the objectives of teaching of appropriate hysterectomy routes have become confused. The aim of all
hysterectomy guidelines is to avoid a laparotomy whenever possible, but a look at the literature reveals the opposite, as there
is a general vaginal school versus laparoscopic school tendency. Current gynecological practice should focus on converting
more AHs into LHs and VHs. Given that the advantages of LH are quite similar to those of VH, we believe that the vaginal
route is the best approach, although there is no doubt that this choice depends on surgical skills, patient characteristics and
available operating facilities. LH may be used to complement a vaginal approach when difficulties and absolute/relative
contraindications are present, or if other pelvic/abdominal procedures are to be performed, as it is an appropriate treatment
for endometriosis or for staging in oncology Guidelines recommend that surgery is performed in dedicated or experienced
units, for us now to prevent this complication our role as a nurse is very vital.

d.) To nursing education what is now the relevance to the nursing education? The nurse is said to be responsible for educating
the patient may it be pre op or even post op, our role might be simple but if we look at it its function is very important, why?
Because if we do not educate our patients about the do’s and dont’s and then they continue to do their ussual habit they may
suffer from further complications such as deep vein thrombosis, malnutrion, and the like. we should also educate our patient
that Immediately surgery, the patient is restricted to a clear liquid diet, which includes foods such as clear broth, diluted fruit
juices or sugar-free gelatin desserts. This diet is continued until the gastrointenstinal tract has recovered somewhat from the
surgery. The next stage provides a blended or pureed sugar-free diet for at least two weeks. This may consist cream of wheat,
a small pat of margarine, protein drinks, cream soup, pureed fruit and mashed potatoes with gravy. Post-surgery, overeating
is curbed because exceeding the capacity of the stomach causes nausea and vomiting. Diet restrictions after recovery from
surgery depend in part on the type of surgery. Many patients will need to take a daily multivitamin pill for life to compensate
for reduced absorption of essential nutrients Because patients cannot eat a large quantity of food, physicians typically
recommend a diet that is relatively high in protein and low in fats and alcohol. When a hysterectomy is decided upon, there
are many circumstances that should be taken into account. Patient opinion and surgeon integrity are transcendental. Many
women are not even informed of which method of hysterectomy they are about to undergo when admitted to hospital.
Patients should be informed of the characteristics of the different routes and their benefits and disadvantages. Clinicians
should ask themselves if the skills and technology available in a medical center are made clear when counseling patients.
Worryingly, some decisions are made during surgery without the scientific evidence to back them up, such as the performing
of a 'free' bilateral adnexectomy. This subject deserves extensive discussion elsewhere, as it is not within the scope of the
present review. We should be conscious of the great negative impact that hysterectomy can have on QoL. Moreover, if the
ovaries are preserved when a hysterectomy is performed between the ages of 50 and 54 years, there is a 10% increase in the
probability of surviving to the age of 80 years. The 0.5% survival advantage estimated as a result of preventing ovarian
cancer is not a convincing enough reason to choose an abdominal approach. Patients put their trust in medical personnel, and
we should make decisions based purely on the scientific evidence available.

Conclusion

Hysterectomy rates are diminishing over time owing to new and effective conservative alternatives. When this intervention is selected,
there are aspects that need to be considered in order for the best route to be selected. Although gynecologists should be trained in the
three routes previously described (vaginal, laparoscopic and abdominal), a rational algorithm should be employed in clincial decisions.
VH should be the first choice for many reasons, the most important of which are lower complication rate, better cost–effectiveness and
improved QoL. The aim of any hysterectomy guideline is to avoid a laparotomy whenever possible. However, it seems that education
concerning appropriate hysterectomy routes is mistaken in its objectives, as the literature continues to demonstrate a conflict between
vaginal and laparoscopic approaches. Current gynecological practice should focus on performing fewer AHs and more LHs and VHs.
Which one of the latter two approaches should be chosen? Given that the advantages of LH are similar to those of VH, we would say
that the vaginal route is preferable, but this is a decision that depends heavily on the skills of the surgeon and the facilities available.

References

1. Dorsey JH, Steinberg EP, Holtz PM. Clinical indications for hysterectomy route: Patient characteristics or physician preference? Am. J.
Obstet. Gynecol. 173,1452–1460 (1995).
2. Kovac SR. Guidelines to determine the route the route of hysterectomy. Obstet. Gynecol. 85,18–23 (1995).
3. Summitt RL Jr, Stovall TG, Steege JF, Lipscomb GH. A multicenter randomized comparison of laparoscopically assisted vaginal
hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet. Gynecol. 92,321–326 (1998).