Hysterectomy Treatment & Management
- Author: Hetal B Gor, MD, FACOG; Chief Editor: Michel E Rivlin, MD more...
Although hysterectomy is often the definitive treatment for many pelvic pathologies, nonsurgical alternatives should always be attempted in elective cases.
Hormonal therapy, gonadotropin-releasing hormone antagonists, progesterone-containing IUD, endometrial ablation, focused ultrasonographic surgery, cryotherapy, and uterine artery embolization have been used with success.
In the 6 states studied, the diffusion of endometrial ablation has had a varying impact on hysterectomy rates among women with benign uterine conditions. However, endometrial ablation is used as an additive medical technology rather than a substitute.
Please see the algorithm below.
In November 1843, Charles Clay performed the first hysterectomy in Manchester, England. The earliest hysterectomies were supracervical, or subtotal, hysterectomies. The body of the uterus was removed while the cervix remained intact. In 1929, Richardson, MD, performed the first TAH, in which the entire uterus was removed.
Prior to an abdominal hysterectomy, the patient undergoes a regional or general anesthetic. A patient remains awake during a regional anesthetic, with only part of the body being numbed to prevent pain. When given a general anesthetic, the patient is unconscious. In the absence of contraindications, neuraxial anesthesia provides a better quality of recovery than general anesthesia.
The abdominal hysterectomy begins via a surgical incision 6-8 inches long, made either vertically, running from the navel to the pubic bone, or horizontally, running along the top of the pubic hairline. The cut exposes the ligaments and blood vessels surrounding the uterus. These ligaments and blood vessels then are separated from the uterus and cervix. In the process, the blood vessels are tied off to prevent bleeding and to help in healing. The uterus and cervix are then cut off at the superior portion of the vagina and removed. The top of the vaginal cuff is closed with sutures, and the surgical wound is closed in layers.
An abdominal hysterectomy may be performed in conjunction with a salpingo-oophorectomy, in which the adnexa are removed, if needed. Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; nerve damage; and urinary tract infection. Candidates for this surgery include those who have fibroids, abnormal or heavy bleeding, chronic pelvic pain, endometriosis, adenomyosis (endometrial tissue that has infiltrated the myometrium), uterine prolapse, cancer of the reproductive organs, or pelvic inflammatory disease.
In a vaginal hysterectomy, the uterus is removed through the vaginal introitus. Prior to surgery, the patient is given a regional or a general anesthetic and the skin surrounding the vagina is prepped with an antibacterial solution. A surgical incision is then made in a circular fashion around the cervix and through the upper vagina to expose the tissue and blood vessels around the cervix and uterus. The tissues and vessels are cut and tied off for the uterus and cervix to be removed from the top of the vagina. The upper part of the vagina, where the surgical incision was made, is then sutured.
Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; nerve damage; and urinary tract infection. Often, colporrhaphy (reconstructive surgery) is performed to repair or prevent cystocele, rectocele, and/or vaginal vault prolapse.
Candidates for this surgery include those who have fibroids, abnormal or heavy bleeding, adenomyosis, uterine prolapse, early-stage cancer of the reproductive organs, or precancerous conditions of reproductive organs.
Laparoscopically assisted vaginal hysterectomy
Laparoscopically assisted vaginal hysterectomy (LAVH) is a procedure that uses laparoscopic surgical techniques and instruments to remove the uterus, cervix, and/or fallopian tubes and ovaries through the vagina. Prior to surgery, the patient is usually given a general anesthetic and the abdomen and vagina are prepared with an antibacterial solution.
LAVH begins with several small abdominal incisions inferior to the belly button, which allow the insertion of the laparoscope and other surgical tools. In order for the surgeon to observe the inside of the body clearly, the peritoneal cavity is inflated with gas (usually carbon dioxide), and a camera, which is attached to the laparoscope, captures and produces a continuous image that is magnified and projected onto a television screen.
Using the laparoscopic surgical tools, the tissues and vessels surrounding the uterus are cut and tied off. The uterus and cervix are then removed through the vagina, and the top of the vaginal cuff is sutured. The fallopian tubes and ovaries also may be removed during this surgical procedure.
Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; nerve damage; and urinary tract infection. Candidates for this surgery include those who have had previous abdominal surgery, large fibroids, chronic pelvic pain, endometriosis, or pelvic inflammatory disease, or those who want an oophorectomy. Today, robotic laparoscopic surgery, such as procedures involving the da Vinci Surgical Robot, is also being refined to evaluate the performance of LAVH.
Laparoscopic hysterectomy (LH) is a procedure in which the uterus and cervix are dissected and ligated from ligaments, tissues, vagina, and blood vessels and removed entirely from small abdominal incisions with the help of instruments like the morcellator. This procedure requires good surgical technique, intra and extracorporal sutures, and different hemostatic devices.
A meta-analysis showed no difference between total LH and vaginal hysterectomy for benign disease in perioperative complications. Total LH was associated with lower pain scores and reduced hospital stay but took longer to perform.
Supracervical hysterectomy is defined as removal of the uterine corpus with preservation of the cervix and can be performed through abdominal, laparoscopic, or robotic approaches.
During supracervical hysterectomy, removal of the corpus is at or below the internal os along with ablation of the endocervical canal. During laparoscopic and robotically assisted hysterectomy, morcellation of the uterine fundus is performed to facilitate its removal through the port site incisions.
Women with known or suspected gynecological cancer, current or recent cervical dysplasia, or endometrial hyperplasia are not candidates for a supracervical procedure.
Evidence regarding the potential benefits of this procedure like less blood loss, shorter operating time, and fewer complications are limited to retrospective series. Patients should be counseled about the need for long-term follow up, the possibility of future trachelectomy, and the lack of data demonstrating clear benefits over total hysterectomy; hence, it should not be recommended by the surgeon as a superior technique for hysterectomy for benign diseases.
Da Vinci surgical system was approved for use in gynecological surgery by FDA in 2005. Da Vinci hysterectomy involves a robotic system in which the surgeon's hands are naturally positioned while his or her fingers grasp the controls below the display, and movements are transferred in real time to surgical instruments inside the patient. This system is useful when the surgery involves dissection in a difficult situation, such as near the ureters, bladder, or blood vessels.
The current system consists of 4 components: (1) console where the surgeon sits and views the screen and controls the robotic instruments, (2) robotic cart with interactive arms, (3) camera and vision system, (4) wristed instruments with computer interfaces.
Advantages are 3-dimensional visualization with improved depth of perception, improved dexterity, less blood loss, shorter hospital stay, less pain, and less risk of wound infection.
Disadvantages include high cost, increased operating time associated with set up and docking, lack of tactile feedback, inability to reposition the patient once the robotic arms are attached, and the bulkiness of the system.
Comparisons of hysterectomy procedures
With the various hysterectomy procedures available, physicians must limit healthcare dollars associated with these surgical procedures while maintaining quality health care for patients. Various studies have been performed to decide which surgical procedure is most suitable in terms of economics and patient health.
The severity of the pathological disorder must be the key standard in selecting the type of hysterectomy, in order to maintain optimum surgical practice. In studies performed in the United States, France, and the United Kingdom in which strict guidelines based on the severity of the pathological disorder have been implemented, most patients underwent successful vaginal hysterectomy without abdominal or laparoscopic assistance.
In a study by Gimbel et al subtotal hysterectomy is faster to perform, has less perioperative bleeding, and seems to have less intra- and postoperative complications. However it does have a slightly high rate of urinary incontinence and cervical stump problems.
Significantly improved outcomes suggest vaginal hysterectomy (VH) should be performed in preference to abdominal hysterectomy (AH) where possible. Where VH is not possible, LH may avoid the need for AH; however, the length of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when the uterine arteries are divided laparoscopically. Also, laparoscopic approaches require greater surgical expertise.
Four-year follow-up data indicate that patients who underwent laparoscopic hysterectomy reported a better quality of life compared to those who underwent AH. Laparoscopic hysterectomy should be considered for patients in whom VH is not possible.
Early feeding (oral intake of fluids or food within 24 h of surgery, irrespective of bowel sounds) after major abdominal gynecological surgery is safe and associated with reduced length of hospital stay but increased nausea. Further studies should focus on the cost effectiveness, patient satisfaction, and other physiological changes.
After the surgery, it takes 4-6 weeks to recover. Recovery is earlier in cases of vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy.
No lifting anything heavy for 6 weeks after the surgery.
In case of oophorectomy in premenopausal women, patients experience menopausal symptoms like hot flashes, vaginal dryness, and mood disturbances.
Return to normal sexual activities is expected after 6 weeks of surgery.
Possible complications of hysterectomy include surgical wound infection; excessive bleeding; injury to the bowel, bladder, ureter, or major blood vessel; urinary tract infection, nerve damage, postoperative thromboembolism, atelectasis, early onset of menopause, and loss of ovarian function. In a 2012 prospective study, hysterectomy with bilateral oophorectomy, compared with hysterectomy with ovarian conservation or natural menopause, was associated with greater increases in BMI in the years following the procedure.
Hur et al found that the 10-year cumulative incidence of dehiscence after any type of hysterectomy was 0.24% and 1.35% after total laparoscopic hysterectomies.
A study by Dessources et al found that postoperative complications were the strongest risk factors for 30-day hospital readmission following hysterectomy, including in women with uterine cancer and in those who underwent hysterectomy for benign conditions. Complications related to readmission included wound complications, infections, and pulmonary emboli and myocardial infarctions, with the 30-day readmission rate being 6.1% among women with uterine cancer and 3.4% for those with a benign disease.
Future and Controversies
As more pharmacologic and invasive radiologic interventions become available, the number of hysterectomies performed in the United States and abroad will continue to decrease.
Compared with hysterectomy, uterine artery embolization (UAE) was associated with higher rates of minor postprocedural complications such as vaginal discharge, postpuncture hematoma, and postembolization syndrome (pain, fever, nausea, vomiting), as well as higher unscheduled visits and readmission rates after discharge. No evidence shows a benefit of UAE over surgery(hysterectomy/myomectomy) for satisfaction. Currently, the ongoing trials REST (UK) and EMMY have yet to report on the long-term follow-up.
Not only will surgical techniques continue to be updated and improved, but preoperative and postoperative interventions will improve morbidity, mortality, and quality of life.
Because the uterus is associated with femininity, some women experience a sense of loss after a hysterectomy. However, some women find a hysterectomy enhances their quality of life because it provides relief of symptoms and definite contraception.
Hysterectomy, whether total or subtotal, may improve quality of life and psychological outcome.
Johns A. Supracervical versus total hysterectomy. Clin Obstet Gynecol. 1997 Dec. 40(4):903-13. [Medline].
Lepine LA, Hillis SD, Marchbanks PA. Hysterectomy surveillance--United States, 1980-1993. Mor Mortal Wkly Rep CDC Surveill Summ. 1997 Aug 8. 46(4):1-15. [Medline].
Zhao SZ, Wong JM, Arguelles LM. Hospitalization costs associated with leiomyoma. Clin Ther. 1999 Mar. 21(3):563-75. [Medline].
Goodwin SC, Wong GC. Uterine artery embolization for uterine fibroids: a radiologist's perspective. Clin Obstet Gynecol. 2001 Jun. 44(2):412-24. [Medline].
Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions reported by US women: findings from the National Health Interview Survey, 1984 to 1992. Am J Public Health. 1996 Feb. 86(2):195-9. [Medline].
Guarnaccia MM, Rein MS. Traditional surgical approaches to uterine fibroids: abdominal myomectomy and hysterectomy. Clin Obstet Gynecol. 2001 Jun. 44(2):385-400. [Medline].
Demello AB. Uterine artery embolization. AORN J. 2001 Apr. 73(4):790-2, 794-8, 800-4 passim; quiz 809-14. [Medline].
Townsend DE, Sparkes RS, Baluda MC. Unicellular histogenesis of uterine leiomyomas as determined by electrophoresis by glucose-6-phosphate dehydrogenase. Am J Obstet Gynecol. 1970 Aug 15. 107(8):1168-73. [Medline].
Gross KL, Morton CC. Genetics and the development of fibroids. Clin Obstet Gynecol. 2001 Jun. 44(2):335-49. [Medline].
Reiter RC, Gambone JC, Lench JB. Appropriateness of hysterectomies performed for multiple preoperative indications. Obstet Gynecol. 1992 Dec. 80(6):902-5. [Medline].
Lee NC, Dicker RC, Rubin GL. Confirmation of the preoperative diagnoses for hysterectomy. Am J Obstet Gynecol. 1984 Oct 1. 150(3):283-7. [Medline].
Weir E. The public health toll of endometriosis. CMAJ. 2001. 164(8):1201.
Greenlee RT, Murray T, Bolden S. Cancer statistics, 2000. CA Cancer J Clin. 2000 Jan-Feb. 50(1):7-33. [Medline].
Duan L, Xu X, Koebnick C, Lacey JV Jr, Sullivan-Halley J, Templeman C, et al. Bilateral oophorectomy is not associated with increased mortality: the California Teachers Study. Fertil Steril. 2012 Jan. 97(1):111-7. [Medline]. [Full Text].
Sawaya GF, Brown AD, Washington AE. Clinical practice. Current approaches to cervical-cancer screening. N Engl J Med. 2001 May 24. 344(21):1603-7. [Medline].
Kovac SR. Which route for hysterectomy? Evidence-based outcomes guide selection. Postgrad Med. 1997 Sep. 102(3):153-8. [Medline].
Catro-Alves LJ, De Azevedo VL, De Freitas Braga TF, Goncalves AC, De Oliveira GS Jr. The effect of neuraxial versus general anesthesia techniques on postoperative quality of recovery and analgesia after abdominal hysterectomy: a prospective, randomized, controlled trial. Anesth Analg. 2011 Dec. 113(6):1480-6. [Medline].
Gendy R, Walsh CA, Walsh SR, Karantanis E. Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials. Am J Obstet Gynecol. 2011 Mar 3. [Medline].
ACOG Committee Opinion No. 388 November 2007: supracervical hysterectomy. Obstet Gynecol. 2007 Nov. 110(5):1215-7. [Medline].
ACOG Technology Assessment in Obstetrics and Gynecology No. 6: Robot-assisted surgery. Obstet Gynecol. 2009 Nov. 114(5):1153-5. [Medline].
Kovac SR. Guidelines to determine the role of laparoscopically assisted vaginal hysterectomy. Am J Obstet Gynecol. 1998 Jun. 178(6):1257-63. [Medline].
Gimbel H. Total or subtotal hysterectomy for benign uterine diseases? A meta-analysis. Acta Obstet Gynecol Scand. 2007. 86(2):133-44. [Medline].
Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2006 Apr 19. CD003677. [Medline].
Nieboer TE, Hendriks JC, Bongers MY, Vierhout ME, Kluivers KB. Quality of life after laparoscopic and abdominal hysterectomy: a randomized controlled trial. Obstet Gynecol. 2012 Jan. 119(1):85-91. [Medline].
Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev. 2007 Oct 17. CD004508. [Medline].
Gibson CJ, Thurston RC, El Khoudary SR, Sutton-Tyrrell K, Matthews KA. Body mass index following natural menopause and hysterectomy with and without bilateral oophorectomy. Int J Obes (Lond). 2012 Sep 25. [Medline].
Hur HC, Donnellan N, Mansuria S, Barber RE, Guido R, Lee T. Vaginal cuff dehiscence after different modes of hysterectomy. Obstet Gynecol. 2011 Oct. 118(4):794-801. [Medline].
Dessources K, Hou JY, Tergas AI, et al. Factors Associated With 30-Day Hospital Readmission After Hysterectomy. Obstet Gynecol. 2015 Jan 7. [Medline].
Gupta JK, Sinha AS, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2006 Jan 25. CD005073. [Medline].
Thakar R, Ayers S, Georgakapolou A, Clarkson P, Stanton S, Manyonda I. Hysterectomy improves quality of life and decreases psychiatric symptoms: a prospective and randomised comparison of total versus subtotal hysterectomy. BJOG. 2004 Oct. 111(10):1115-20. [Medline].
Farquhar CM, Naoom S, Steiner CA. The impact of endometrial ablation on hysterectomy rates in women with benign uterine conditions in the United States. Int J Technol Assess Health Care. 2002 Summer. 18(3):625-34. [Medline].
Jacobson GF, Shaber RE, Armstrong MA, Hung YY. Hysterectomy rates for benign indications. Obstet Gynecol. 2006 Jun. 107(6):1278-83. [Medline].