Hysterectomy

Max Brinsmead MB BS PhD

June 2015
Indications for Hysterectomy
 Fibroids
 Menstrual dysfunction
 Prolapse
 Endometriosis
 Adenomyosis
 Pelvic Inflammatory Disease
 Cancer
 Cervix
 Uterus
 Ovaries
Alternatives to Hysterectomy
 Medical treatment of bleeding problems or
endometriosis
 Endometrial resection for menorrhagia
 Myomectomy and uterine artery embolisation
for fibroids
 Radiotherapy for Ca cervix

 A number of RCT’s and systematic analyses

compare these alternatives
 So clinician-guided and informed patient choice
is an important component of best practice
Types of Hysterectomy
 Subtotal Hysterectomy
 Uterine body only
 Total Hysterectomy
 Uterine body and cervix (not ovaries!)
 Hysterectomy with BSO
 Uterus with bilateral salpingo oophorectomy
 Radical (or Wertheim) Hysterectomy
 Total hysterectomy with pelvic lymph nodes,
paracervical tissue and upper 1/3 vagina
Routes for Hysterectomy
 Abdominal Hysterectomy (AH)
 Total
 Subtotal

 Vaginal Hysterectomy (VH)

 Laparoscopic Hysterectomy
 Laparoscopically-assisted vaginal (LAVH)
 Totally laparoscopic hysterectomy
Which Route is Best?
 Abdominal Hysterectomy
 Results in greatest mean blood loss
 Has the highest incidence of febrile morbidity
 And abdominal wound infection (obviously)
 Longest hospitalisation
 And slowest to recover
 Vaginal Hysterectomy
 Is the preferred route when technically possible
 Laparoscopic Hysterectomy
 Requires training and equipment
 Longest operating time
 But shortest hospitalisation and recovery
 But has the greatest overall risk of complications
 There is debate about its cost effectiveness
Complications of Hysterectomy
 Infection
 Abdominal incision
 Vaginal vault and pelvic
 Infected haematoma
 Blood loss and anaemia
 Bladder dysfunction or Cystitis
 Bowel dysfunction
 Damage to:
 Bladder
 Bowel
 Ureters
 Depression or Sexual Dysfunction
 Longer Term
 Prolapse
 Wound pain
 Earlier menopause
 “Ball-Park” Risks with
Hysterectomy
 30 – 40% minor complication rate
 1:10 risk of “unpleasant” complication
 1:20 risk of transfusion
 1:50 risk of serious complication
 But <1:100 with ongoing problems
 1-3:1000 risk of death

 Complications are some 1.5-fold more

common if there are fibroids
Hysterectomy complication rates from long-term
cohort studies
Hysterectomy complications from Cochrane
RCT’s
 NICE recommendations concerning Hysterectomy
for Heavy Menstrual Bleeding

 It is not treatment of 1st choice but

recommended when…
 Women who have no wish for future fertility
 Desires amenorrhoea
 And is fully informed
 Information required…
 Implications of the surgery
 Sex & psychological functions
 Risks and complications in some detail
 Bladder function
 Need for further surgery
 Pros and cons of oophorectomy
 NICE recommendations concerning route of
Hysterectomy

 Factors that influence this decision include…

 Nature of any gynaecological disease
 Presence/Size of any fibroids
 Mobility and descent of the uterus
 Shape and size of vagina
 History of any previous surgery
 Vaginal hysterectomy (VH) is the route of 1st
choice
 If oophorectomy is required then
Laparoscopically-assisted VH is best
 If abdominal hysterectomy (AH) is performed
then subtotal (leaving the cervix) is an option
 Removal of the Cervix

 Is only an option during abdominal hysterectomy

 Technically more difficult
 So operative time and blood loss is increased
 So leave the cervix when things are going badly
 Some evidence for more bladder problems when
it is left (about 2-fold)
 Sometimes “mini periods” if it is left (about 7%)
 2% risk of cervical prolapse when it is left
 Main argument for removal is risk of CIN and Ca
 But the cervix does not have any sexual function
 Confirmed by RCTs
 Bilateral Oophorectomy during
Hysterectomy?
 1:80 lifetime risk of ovarian cancer
 Bilateral oophorectomy reduces the risk of breast Ca
 Is more important for the woman at risk
 e.g. those with BRAC1&2 mutations
 Up to 1:10 pre menopausal women undergoing
hysterectomy return for surgery to remaining ovaries
 This can be technically difficult
 And PMT-symptoms can be a major problem for a few
women
 Oophorectomy may be important if there is peritoneal
endometriosis
 Adds little to operative time and risk during AH
 But may be quite difficult in up to 30% during VH
 Bilateral Oophorectomy during
Hysterectomy 2?
 The major problem is that of premature menopause
 And symptoms from a surgical menopause seem to
be more severe
 Many women feel very strongly about ovarian removal
 There is a dearth of information about any endocrine
role for postmenopausal ovaries
 They continue to produce androgens
 Which may have a role in well-being and libido
 And are converted to oestrone by fat cells
 Age is one factor that has a major role in deciding
about bilateral oophorectomy
 Below the age of 45 – aim for preservation
 Above the age of 65 – balance tips in favour of removal
NICE recommendations concerning Oophorectomy
during Hysterectomy

 Healthy ovaries should not be routinely

removed
 Oophorectomy should only be performed with
a woman’s expressed wishes and consent
 If ovarian cycling is thought to be contributing
to symptoms then a trial of GnRH for 3-4
months before hysterectomy may be useful
 Women who elect to have or require bilateral
oophorectomy need advice about…
 Impact on the risks of ovarian & breast Ca
 Pros and cons of oestrogen hormone therapy
(ERT)
 Bilateral Salpingectomy during
Hysterectomy?
 Emerging evidence that the fallopian tube, and not
the ovaries, are the source of many adenoCa has
meant that…
 Removal of both fallopian tubes is becoming
standard practice during hysterectomy
 However…
 With the exception of patients with BRAC genes,
there is no evidence yet that this will reduce the
incidence of ovarian cancer after hysterectomy
 And there are concerns that this step will further
compromise the blood supply to any retained ovaries
 After Hysterectomy
 Most women don’t need Pap smears
 Except those who had previous CIN >2 , Ca
Cervix or Ca corpus uterus

 Oestrogen only HRT (ERT) is an option

 Except when BSO was performed for oestrogen
responsive cancer or severe endometriosis
 Symptoms control in these patients can be a real
problem
 Current research suggests that ERT has many
benefits and few risks
 Any Questions or
Comments?

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