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Overview of current trends

in hysterectomy
Expert Rev. Obstet. Gynecol. 4(6), 673–685 (2009)

Santiago Domingo
and Antonio Pellicer†
†
Author for correspondence
Department of Obstetrics
and Gynecology, Hospital
Universitario La Fe, Avda,
Campanar 21,
46009 Valencia, Spain
Tel.: +34 963 050 985
Fax: +34 963 050 999
apellicer@ivi.es
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. 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.

Keywords : abdominal • benign uterine disease • guideline • hysterectomy • laparoscopic • vaginal

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 per-
formed intra-abdominal surgery. The majority of
gynecologic surgeons continue to perform hyster-
ectomies by means of a laparotomy, while chole-
cystectomy 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 [2] . 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 manip-
ulation, pelvis dissection and easy removal of the
specimen. Vaginal hysterectomy (VH) is the saf-
est route and has the best cost–effectiveness ratio,
making it the first-choice option in clinical prac-
tice. 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 rel-
egated to the end of the list of options. Scientific
evidence favors VH and laparoscopic hysterec-
tomy (LH), which have lower complication rates,
produce less postoperative pain and shorter hospi-
tal stays, and allow a more rapid return to normal
activity, thereby resulting in a better quality of
life (QoL) [3–5] .
Laparotomy continues to be the preferred
method for hysterectomy in approximately
60–70% of benign uterine processes [1] . 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 poten-
tially 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 con-
cerning hysterectomy in healthcare centers and
gyneco­logical programs. Although hysterectomy

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 Review Domingo & Pellicer
rates in Western countries are diminishing owing to a generally
more conservative approach, and this operation is still widely per-
formed [6] . However, rates differ considerably between countries,
ranging from a high of 5.4 per 1000 women in the USA [7] to inter-
mediate rates, such as 3.7 per 1000 in Italy [8] , 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 [10–14] .
The conditions that may lead to a hysterectomy cause discom-
fort 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 other­
wise 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 consti-
tuting the leading pathologies of the uterus. There is a 20–25%
incidence of uterine fibroid tumor in women of fertile age [16] 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 para-
cetamol) and anovulatories; however, if necessary, surgery of the
adnexa (endometrioma) is indicated. A hysterectomy may be pro-
posed 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 hemor-
rhage are less frequent indications and account for only 10% of
the total rate of hysterectomies.
Should bilateral salpingo-oophorectomy be indicated?
Hysterectomy does not modify the risk of mortality from cardio­
vascular disease or cancer [17] but should be adequately evalu-
ated in cases of concurrent 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. Some years ago, it
was estimated that 7.1% of future deaths would be prevented by
concurrent salpingo-oophorectomy, mainly owing to avoiding
674
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 hys-
terectomy 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 [21] . Recently, it
has been concluded that preserving ovaries until at least the age
of 65 years was associated with higher survival rates [22,23] .
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 [24] . 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 inter-
pretation, 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
The American College of Obstetricians and Gynecologist’s
(ACOG) guidelines for hysterectomy are probably the most
widely accepted and most employed of those found in the lit-
erature [2] . The most determinant factors for choosing one or
another approach are surgeon skill, uterus size, uterine mobility,
nulliparity and previous pathological conditions (Box 1) .
Surgeon skill
Age, parity, uterine size, vaginal anatomy, pelvic mobility and any
pelvic disease or previous pelvic surgery are among the most impor-
tant 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 effec-
tive guidelines for the determination of the route of hysterectomy
Expert Rev. Obstet. Gynecol. 4(6), (2009)

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 determi-
nant 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, dis-
advantages and outcomes of AH and VH for enlarged symptomatic
uteri between 200 and 1300 g have clearly demonstrated the advan-
tages of the vaginal route in terms of operative times, febrile mor-
bidity, 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 sur-
geons 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 determin-
ing the route of a hysterectomy. A vaginal route is usually indi-
cated 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 hyster­
ectomy. 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
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Overview of current trends in hysterectomy Review
Box 1. Items in selecting hysterectomy route.
• Evaluate vaginal access and confirm good vaginal fornix
• Estimate uterine size, and myoma size, number and localization
• Evaluate feasibility of vaginal morcellation
• Confirm uterine mobility and descent
• Evaluate pathological conditions, such as previous pelvic surgery
or possibility of endometriosis/adhesions
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 possi-
ble 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 con-
sensus 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 clini-
cal decision-making process. The SPRS practice guidelines com-
ply 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 patho-
logical circumstances and the patient’s characteristics preclude the
vaginal and/or laparoscopic route [2,37–39] . The hysterectomy via
abdominal route has traditionally been chosen when the uterus was
675
 Review Domingo & Pellicer
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 essen-
tial that all these circumstances are evaluated but, in reality, many
of them have never been sufficiently analyzed [1] . Fortunately, since
the arrival of laparoscopic surgery, the majority of these vaginal
contraindications can be resolved with laparoscopy. Thus, previ-
ous 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 [40] .
Vaginal hysterectomy
Vaginal hysterectomy should be the standard procedure for remov-
ing 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 [40] .
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 [44] . 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 [25,45,46] .
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
Figure 1. Morcellation of a miomatous uterus during a
vaginal hysterectomy.
676
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-oopho­
rectomy 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 post-
menopausal 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 liga-
ment stump to include the full length of the infundibulo–pelvic
ligament. Other systems can be employed if anatomical difficul-
ties 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] .
Uterus morcellation can be a challenge, often because of the
use of inappropriate techniques. The ACOG’s 1989 guidelines for
choosing the appropriate route for a hysterectomy state that the
choice “depends on the patient’s anatomy and the surgeon’s expe-
rience” and that the operation is usually accomplished in women
with mobile uteri that are not larger than those at 12 weeks of
gestation (280 g) [30,39] . As the normal size of a uterus is less
than that at 12 weeks gestation, it is usually enough to simply
pull in order to deliver it. However, although a uterus at more
than 13 weeks gestation can also be easily removed through the
vagina, the procedure can be complicated. To overcome these
problems, various complementary methods have been described
that permit progressive reduction of the volume of the uterus dur-
ing surgery, such as myomectomy, morcellation, corporal bisec-
tion and intramyometrial coring (Figure 1) . Once uterine arteries
have been sutured, blood supply to the uterus is dramatically
diminished (~75–80%), allowing a safe morcellation without
blood loss [48,49] . Successful large uterus VHs (>1000 g) have been
reported employing these techniques [32] . Unger reported that
vaginal removal of large uteri (200–700 g) with respect to uteri
with volumes less than 200 g is not associated with an increase in
complications or length of hospital stay but only with the dura-
tion of the operation, which increases directly in proportion to
uterine weight [50] . In recent years, several authors have combined
VH with laparoscopic assistance in such circumstances without
observing any advantages over the standard vaginal route [41] .
Laparoscopic hysterectomy
The role of LH remains difficult to define, in spite of the exten-
sive scientific evidence available. Its ultimate aim is to reduce
the rate of AH rather than that of VH. Initially, laparoscopy
Expert Rev. Obstet. Gynecol. 4(6), (2009)

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 opera-
tion 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 reduc-
ing 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 laparo­
scopically [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 [53] .
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 laparo-
scopically 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 endo­
metriosis implants by means of different systems (excision, coagu-
lation 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 men-
tioned 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 com-
pared with other techniques. The literature contains four ran-
domized control trials comparing VH with LH [37,55–57] . LH
was constantly associated with longer operation times than
VH, but with no differences in hospital stay, postoperative pain
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Overview of current trends in hysterectomy Review
sensation or postoperative recovery. In total, 12 randomized,
controlled trials compared LH with AH [3,57–67] , and all con-
firmed 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 nul-
liparous or obese patients [71,72] . 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 facili-
tate dissection and colpotomy. This instrument significantly
reduces the operating time and complication rate (usually vesi-
cal and ureteral injury) and permits a more reproducible tech-
nique. Uterine manipulators should not be employed in cases
of endometrial malignancy, as it can increase the hypothetical
risk of vaginal relapse [73] .
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 afore-
mentioned 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 occur-
rence of major complications; it highlighted that, after 30 LHs,
bladder and ureter injuries were far less frequent [74] .
There are no absolute contraindications for laparoscopy, and
relative circumstances are usually related to general anesthe-
sia and hypothetical problems in the abdomen entry. Morbid
obesity (BMI > 30) is often a challenge when establishing the
pneumo­peritoneum. Previous abdominal scars, especially mid-
line 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 hyster-
ectomy has been published to date, but reports that favor this
approach are beginning to appear [75,76] . This approach offers
the patient another minimally invasive option in addition to
laparoscopy or VH.
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 Review Domingo & Pellicer
Box 2. Classification of laparoscopic hysterectomy.
Laparoscopic-assisted vaginal hysterectomy
• Laparoscopic assistance does not involve the ligation of
uterine vessels
Uterine vessel ligation laparoscopic hysterectomy
• Uterine vessels are secured laparoscopically, but surgery is
completed via the vagina
Total laparoscopic hysterectomy
• The whole hysterectomy is performed laparoscopically
Hysterectomy complications
The two fundamental aspects to be considered when studying
hysterectomy complications are surgical and functional.
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 dif-
ference 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 hos-
pital 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 sup-
ply 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 [77,78] . The Maryland Women’s
Health study, the largest prospective study to date, investi-
gated the effects of hysterectomy with and without concomi-
tant urinary incontinence repair on incontinence severity [79] .
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,
678
hysterectomy reduced previous urge-frequency symptoms, and
new symptoms were observed in only 4% of cases at 1-year fol-
low-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 [80,81] . 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 dysfunc-
tion 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 out-
come measures [82] . Most studies have shown either no change or
an enhancement of sexuality following hysterectomy. Even when
compared with more conservative management (endo­metrial abla-
tion), no differences have been found [83] . Conservation of inner-
vation 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 hysterec-
tomy [84] , 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% [85] . It occurs more fre-
quently 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 [87] .
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 [88] .
Expert Rev. Obstet. Gynecol. 4(6), (2009)

Gonadotropin-releasing hormone agonists can lead to amen-
orrhea 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 [89] .
Mifepristone, an antiprogesterone agent, has proved its useful-
ness 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 eleva-
tion 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 aim-
ing 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 [94] ,
with a definite hysterectomy rate of approximately 10% [95] . One
of the risks that must be assumed with this approach is an unex-
pected hysterectomy owing to surgical complications, in particular,
intraoperative bleeding.
In the past, myomectomy has usually been performed abdomi-
nally but, nowadays, a laparoscopy/hysteroscopy is feasible [96] .
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 bleed-
ing and pain, and are successfully removed in a high percentage
of cases with this technique (85–95%) [97] . As with abdomi-
nal/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 uro-
logical type resectoscope, a rollerball or laser ablation. All require
previous endometrial preparation in order to diminish the thick-
ness 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
www.expert-reviews.com
Overview of current trends in hysterectomy Review
different techniques employed [99–101] . Generally, these outcomes
are positive, with high satisfaction rates (~75%) and QoL meas-
ures and a positive balance in post-treatment hemoglobins being
reported [99] . This approach has been compared with hyster­ectomy
in randomized trials, yielding better outcomes in operation time,
hospital stay and direct costs [102,103] .
These treatments are known as first-generation endometrial abla-
tion techniques, which distinguishes them from the wide range
of new methods for removing or destroying the endometrium
more rapidly and safely [104] . They do not depend heavily on the
skill of the surgeon, contrary to selective methods, which explains
the positive development of these new technologies [105] . 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 inter-
val (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 [106] . 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 fur-
ther 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 [107–109] .
Levonorgestrel-releasing intrauterine device
The LNG-IUD is one of the most important advances in the con-
servative 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 aver-
age 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 [111] . 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 amenor-
rhea rate [112] . In this way, LNG-IUD is probably the best of the
conservative approaches to treating menorrhagia [110] .
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
679
 Review Domingo & Pellicer
costs associated with long-term use of oral therapy can be surpris-
ingly high, while LNG-IUD has been shown to incur the lowest
cost among available therapies [113] . That said, in many countries,
oral progestins continue to be the most frequently prescribed
medical therapy for menorrhagia [114] .
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 seda-
tion, 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 [115] . 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, menor-
rhagia 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 [117] .
This procedure represents some complications that should be
taken into account. One technical difficulty is the impossibility
of cannulating the artery owing to anatomical variations, tortu-
osity of the vessels or inadvertent vessel damage. Fibroid expul-
sion constitutes another drawback in approximately 10% of cases,
particularly in cases of submucous myomas. This can cause a
good deal of pain due to infection with prolonged leucorrhea, and
can require surgical intervention when expulsion is incomplete.
Uterine embolization induces pain in variable degrees because of
myoma ischemia, requiring treatment with opiates, which rules
out the day-out procedure. Another important concern regard-
ing the side effects of this procedure is secondary amenorrhea
due to ovarian compromise [118] . For clinicians, these complica-
tions represent barriers to the implantation of this procedure,
with the exception of patients with menorrhagia, for whom it
offers an option of conservative management. Nevertheless, the
complication rate associated with uterine artery embolization is
lower than that of hysterectomy and, if the management of events
following embolization is improved, particularly with respect to
those regarding fertility, this approach can constitute an effective
alternative [119] .
Ultrasound-focused therapy
The rationale of ultrasound-focused therapy is based on ultra-
sound-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 dam-
age, leading to coagulative necrosis due to thermal and nonthermal
effects produced in the exposed area. The depth between the skin
680
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 neces-
sary, 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 improve-
ment (e.g., pain or heavy bleeding) is significant. Long-term results
are necessary in order to discern its real cost–effectiveness [121] .
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, laparo-
scopic and abdominal), a rational algorithm should be employed
in clincial decisions. VH should be the first choice for many rea-
sons, 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 pos-
sible. 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 laparo-
scopic 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.
Expert commentary
One of the greatest achievements of the hysterectomy policy is
the reduction in the rate of hysterectomy indication. The LNG-
IUD, among the most important advances in menorrhagia treat-
ment, and other conservative approaches are to be thanked for
this progress. This situation will probably continue, although
we suspect that these methods are not as widespread in medical
practice as they should be. One of the adversities that clinicians
must struggle with is a lack of knowledge regarding the benefits
offered to patients by alternative therapies. Why does clinical
decision making not evolve with new advances? Currently, many
women enter the operating theater without having been submit-
ted to more conservative approaches or at least having discussed
alternatives with medical staff. Another regrettable circumstance
is the economic impact for a surgeon of avoiding surgery, which
can lead to misguided priorities in the decision of whether or not
to perform a hysterectomy.
When a hysterectomy is decided upon, there are many circum-
stances 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
Expert Rev. Obstet. Gynecol. 4(6), (2009)

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 sur-
geons 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.
What direction must we take in the future? First, we must
improve the training of resident doctors in vaginal surgery. Vaginal
anatomy is often taught inadequately. The ability to perform some
of the technical aspects of VH, such as opening the anterior and
posterior peritoneum, is often more of a challenge than a ‘usual
practice’. These steps should be as routine as opening abdomen
layers for a gynecologial surgeon. Clinicans need to lose their fear
of uterus morcellation. This procedure is uncomplicated in most
cases as, fortunately, it is not commonly performed in uteri of sizes
larger than those at 12 weeks of pregnancy. Once uterine vessels
are clamped, one to three vaginal myomectomies are enough to
remove the uterus from the pelvis. Although many surgeons and
residents are not accustomed to this procedure, morcellation is a
safe step in vaginal delivery. Second, gynecological centers need
to update their clinical guidelines for the treatment of pathologies
www.expert-reviews.com
Overview of current trends in hysterectomy Review
of the uterus. A decision-making algorithm offers gynecologists
a more structured surgical approach, avoiding personal practice
styles that may favor a single route or method. Third, all medical
decisions should be based on available scientific evidence. A con-
tinuous updating of knowledge should form an integral part of our
professional life, as what is current in the present quickly becomes
outdated in the future. We cannot rely soley on what we learnt
in our residence programs, but must constantly move forward by
updating our training and allowing our surgical techniques and
their indications to evolve.
Five-year view
Hysterectomy policy requires a change. It is essential to explore all
the medical tools available to treat uterine disease in order to offer
our patients more conservative treatments rather than surgery.
Global surveillance of women’s health is improving, and reaching
the eighth decade is normal in developed countries. Hysterectomy
rates are expected to decrease as, although the genital prolapse
rate is sure to rise, menorrhagia, the most frequent indication for
a hysterectomy, is increasingly treated with more effective alterna-
tive methods. The scenario in the developing world is different,
with menorrhagia often posing a life-threating problem, making
hysterectomy the first and sole treatment for the related anemia.
Randomized studies of the long-term outcomes of new
alternatives compared with those of hystererectomy need to be
updated, focusing on cost–effectiveness, QoL and complica-
tions. We believe that the LNG-IUD will have an important
impact on the treatment of menorrhagia in the future, as its
clinical application increases yearly. Moreover, the LNG-IUD
may play an enormous role in preventing endometrial pathology,
owing to its strong antiproliferative effect. Studies are required
to evaluate its preventive efficacy in endometrial hyperplasia.
Many patients with risk factors (e.g., obesity or polycystic ovar-
ian syndrome) are sure to benefit from advances that prevent
pathologies and consequential hysterectomies. Newly available
drugs, such as the progestin receptor modulators, are promis-
ing alternatives. In addition, new second-generation ablation
techniques will no doubt improve their results with time and
become serious rivals of hysterectomy. Why is ablation not
applied in clinical practice as frequently as it should be? The
fact that this approach is unsuccessful among almost a quarter
of patients 5 years after the procedure is discouraging. Future
research should focus on a definitive destruction of the basal
endometrium and, if possible, a definitive sinequia of the entire
endometrial cavity.
National healthcare systems should monitor hysterectomy pol-
icy, as it is one of the most prevalent surgeries among the popu-
lation. How much money could be saved if standard guidelines
were followed? New criteria must be considered when selecting
the route of hysterectomy, and vaginal surgery programs should
be promoted. There is a need for vaginal and laparoscopic surgery
training programs in every country and institution. Reports con-
tinuously show that VH/AH rates can be dramatically changed
without surgical complications. It is more than probable that, in
a few years, such changes will be undertaken in many centers, as
681
 Review Domingo & Pellicer

patients will demand a less invasive approach to treating their prob-
lems. Laparoscopic surgery is increasingly accessible to gynecologic
surgeons and surgical devices, such as uterine manipulators and
sealing systems, make surgery easier to perform and more repro-
ducible. Robotic surgery shows great potential. Its short learning
curve, the 3D view it affords, and the better access to the pelvis
and deep pelvis that it allows (owing to the instrumental tips)
convert it into an attractive alternative, although its excessive cost
makes it an unfeasible option for such a prevalent form of surgery.
Although all surgeons should be well trained in both vaginal and
laparoscopic procedures, it is likely that controversy surrounding
the two approaches will continue. We believe that, in a few short
years, current AH rates will have been reduced radically so that
they account for less than 10% of surgical procedures.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.

Key issues
• Hysterectomy is one of the most prevalent surgeries in the female population and, although a vaginal route is recommended by many
institutions, a laparotomy is still commonly performed.
• Hysterectomy indications show a slow but continuous diminution owing to the availability of more conservative approaches, including
levonorgestrel-releasing intrauterine devices, ablation techniques and uterine embolization, which have been shown to be safe and
cost effective.
• Menorrhagia is the first cause of surgery, mainly as a result of myomas and adenomyosis. Other common indications are genital
prolapse and malignancy.
• Hysterectomy appears to be cost effective as a treatment for menorrhagia compared with endometrial resection, ablation and medical
therapy at long-term follow-up.
• The vaginal route is the most cost-effective approach to hysterectomy, and has been shown to be an effective and cost-effective
intervention for a variety of indications.
• Vaginal hysterectomy should be the first choice when selecting the route of intervention. Laparoscopic surgery (assistance or a total
hysterectomy) should be performed if an absolute/relative contraindication is suspected.
• Parity, uterine size, vaginal anatomy, pelvic mobility and any pelvic disease or previous pelvic surgery are the most important factors
influencing the choice of hysterectomy route. The most transcendental of all is the skill of the surgeon in question.
• Uterine size should not be an indication for abdominal surgery, as vaginal morcellation is a safe and effective alternative in such cases.
• The preservation of ovaries until the age of at least 65 years is associated with higher survival rates, as this prevents cardiovascular
disease and hip fracture.
• Abdominal hysterectomy should be performed only when pathological circumstances and patient characteristics preclude the
vaginal/laparoscopic route.

cost among women undergoing 11 Wilcox LS, Kononin LM, Pokras R,

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Affiliations
• Santiago Domingo, MD
Department of Obstetrics and Gynecology,
Hospital Universitario La Fe, Avda,
Campanar 21, 46009 Valencia, Spain
Tel.: +34 963 050 985
Fax: +34 963 050 999
sdomingo@ivi.es
• Antonio Pellicer, MD
Department of Obstetrics and Gynecology,
Hospital Universitario La Fe, Avda,
Campanar 21, 46009 Valencia, Spain
Tel.: +34 963 050 985
Fax: +34 963 050 999
apellicer@ivi.es
685