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					                                    Hysterectomy

    INTRODUCTION — Hysterectomy (surgical removal of the uterus) is the most
    commonly performed gynecological surgical procedure. In 2003 to 2004, over
    600,000 hysterectomies were performed annually in the United States, of which
    approximately 90 percent were done for benign conditions [1]. The distributions of
    abdominal and vaginal hysterectomy were similar; 12 percent of all hysterectomies
    were performed laparoscopically. Six percent of all hysterectomies were
    supracervical. However, the prevalence of hysterectomy appears to be decreasing,
    possibly due to the advent less invasive therapies for management of conditions
    previously treated with hysterectomy, and in recent years vaginal hysterectomy has
    become more common [2].


    Once the decision has been made to proceed with hysterectomy, the physician and
    patient must decide whether the procedure will be performed abdominally, vaginally,
    or with laparoscopic assistance. The optimal surgical approach is unclear because
    there are few data from large, well-designed randomized trials on which to base a
    recommendation. The route chosen depends upon the woman's clinical
    circumstances and the surgeon's technical expertise; the surgeon's personal
    preference also plays a major role.


    INDICATIONS — There are five broad diagnostic categories of indications for
    hysterectomy:


          Uterine leiomyomata
          Pelvic organ prolapse
          Pelvic pain or infection (eg, endometriosis, pelvic inflammatory diseases)
          Abnormal uterine bleeding
          Malignant and premalignant disease


    The reason for the hysterectomy, risks and benefits of the procedure, alternatives,
    and expectations for outcome should be discussed with the woman in detail. Since a
    number of the indications for hysterectomy are based more upon opinion than
    evidence from well-designed studies, informed consent with thorough exploration of
    patient preferences and expectations is particularly important [3]. In the absence of
    a life-threatening emergency (eg, uterine hemorrhage), the decision to proceed with
    hysterectomy is made mutually by the woman and her physician based upon her
    functional impairment, childbearing plans, response to medical therapy, discussion of
    alternatives, and perception that the risks of the procedure are outweighed by the
    expected benefits.


    TREATMENT ALTERNATIVES — Medical and surgical alternatives to hysterectomy
    depend upon the underlying disorder. As an example:


          Uterine artery embolization and myomectomy may be used to treat
    symptomatic leiomyoma. (See "Interventional radiology in management of
    obstetrical and gynecological disorders" and see "Myomectomy").
          Pain control services may be able to return patients with intractable pelvic
    pain to a functional status without surgery. (See "Causes of chronic pelvic pain in
    women").
          Endometrial ablation may be an effective therapy for excessive uterine
    bleeding. (See "Endometrial ablation").
          Medical therapy using GnRH analogs can help reduce discomfort associated
    with endometriosis. (See "Overview of the treatment of endometriosis").
          Endometrial hyperplasia can sometimes be treated medically with progestins.
    (See "Endometrial hyperplasia").
          Conization (eg, cold knife, loop electrosurgical excision procedure) may be
    adequate therapy for some women with high grade cervical intraepithelial
    neoplasia/carcinoma in situ. (See "Cervical intraepithelial neoplasia: Management"
    and see "Cervical intraepithelial neoplasia: Procedures for cervical conization").


    Additional medical and surgical options for management of conditions treated by
    hysterectomy are discussed in individual topic reviews on each subject. A comparison
    of outcome after hysterectomy versus medical therapy for abnormal uterine bleeding
    can be found separately. (See "Menorrhagia" section on Medical versus surgical
    therapy).


    PREOPERATIVE ISSUES — An overview of issues pertaining to preoperative
    preparation and assessment can be found separately. (See "Preoperative evaluation
    and preparation of women for gynecologic surgery", section on Preoperative
    preparation and section on Informed consent, and section on Antibiotic prophylaxis).


    Women should be provided with clear information about what to expect during their
    hospitalization and regarding return to normal activities. Education during the
    preoperative office visits will enhance the patient's acceptance and compliance
    during the immediate postoperative period and may help to shorten hospital stay.
    SURGICAL PLANNING


    Surgical approach — Hyterectomy may be performed using one or a combination
    of the following approaches, including:


          Abdominal
          Vaginal
          Conventional laparoscopic
          Robot-assisted laparoscopic


    The choice of surgical approach depends upon the indications for the procedure,
    concomitant procedures, surgical outcomes of each approach, surgeon experience,
    and patient preference.


    In general, a surgeon should choose the procedure which maximizes patient safety
    and best achieves the goal of the operation. Recent developments in gynecologic
    surgery have expanded the minimally invasive options for hysterectomy. Less
    invasive procedures, when possible, are typically preferrable to more invasive
    procedures.


      Abdominal versus vaginal hysterectomy — Most studies (randomized and
    observational) have concluded that vaginal hysterectomy should be the preferred
    route of hysterectomy because it is associated with fewer complications, shorter
    length of hospitalization, and lower hospital charges than abdominal hysterectomy
    (show table 1) [4-6], although a large Finnish study reported discordant findings [7].
    Data from observational studies must be interpreted with caution as the route of
    hysterectomy is likely to have been influenced by the severity of underlying disease
    and complexity of the procedure.


    Historically, abdominal hysterectomy has been designated as the appropriate route
    for more serious conditions believed to necessitate a more thorough abdominopelvic
    exploration, as well as procedures deemed too difficult to perform through the vagina
    [8-10]. This opinion was the result of poorly defined, but traditionally accepted,
    contraindications to the vaginal route, including: uterine enlargement (uterine weight
    estimated <280 g [a normal uterus weighs 70 to 125 g] or uterine size less than 12
    weeks); vagina deemed "too narrow" (eg, vagina narrower than 2 finger-breadths,
    especially at the apex); lack of uterine descensus and mobility; presence of adnexal
    disease; prior pelvic surgery; malignancy; contracted pelvis; and need to explore the
    upper abdomen [4]. However, these traditional indications for laparotomy have been
    challenged [9,11-14]. There are no randomized trials examining these factors.
    Examples of evidence from observational series supporting fewer exclusions to the
    vaginal approach are presented below:


          Uterine mobility — While greater uterine mobility is typically associated with
    prior vaginal delivery, vaginal hysterectomy is not contraindicated in nulliparous
    women [15]. A prospective study attempted to determine the importance traditional
    factors in route of hysterectomy by encouraging a vaginal approach in all cases [12].
    All patients without prolapse undergoing hysterectomy for benign conditions were
    included, except those with adnexal/tuboovarian disease, evidence of extensive
    endometriosis with associated uterine immobility, disease outside the pelvis
    necessitating abdominal exploration, and uterine size estimated at greater than 16
    weeks. There were 97 abdominal and 175 vaginal procedures, with no significant
    differences in patient characteristics (eg, nulliparity, prior cesarean). Over the five
    years of the study, the proportion of abdominal hysterectomies fell from 68 to 5
    percent. The frequency of complications was low and similar in both groups. Most
    associated oophorectomies at the fifth year were also performed at the time of
    vaginal hysterectomy with no associated increase in morbidity.


    These results suggest that lack of prolapse/descensus may not be valid reason for an
    abdominal approach, even in nulliparous women and those with a prior cesarean
    delivery. However, lack of descensus due to normal pelvic support should be
    differentiated from uterine immobility due to dense adhesive disease. If the patient's
    history suggests the latter, an abdominal or laparoscopic approach is indicated.


          Uterine size — A prospective study evaluated vaginal hysterectomy outcome
    in 204 consecutive women with a myomatous uterus weighing 280 to 2000 g and/or
    one or more of the commonly considered contraindications to a vaginal approach
    (eg, prior pelvic surgery, history of pelvic inflammatory disorder, moderate or severe
    endometriosis, concomitant adnexal mass, nulliparity, limited vaginal access) [9].
    Vaginal morcellation was performed in all cases and no patient had uterovaginal
    prolapse. Four patients underwent conversion to a laparoscopic procedure for the
    completion of the hysterectomy, but two of these ultimately required laparotomy.
    Adnexectomy was successfully performed vaginally in 90.6 percent of patients in
    whom it was indicated.


    These findings suggest that traditional uterine weight criteria for exclusion of the
    vaginal approach may not be valid.
            Prior cesarean delivery — Surgeons have been reluctant to perform vaginal
    hysterectomy in woman with a prior cesarean delivery due to concerns about
    scarring in the lower uterine segment leading to bladder trauma, excessive bleeding,
    and eventual failure of the vaginal route. These issues were evaluated in a
    retrospective review that compared vaginal hysterectomy outcome of 220 women
    with prior cesarean deliver (one or more) to 200 patients with no previous pelvic
    surgery [13]. Only three of the 220 patients had inadvertent urological trauma
    intraoperatively. Factors favoring a successful vaginal approach were only one
    previous cesarean, a freely mobile uterus, previous vaginal delivery, uterus not
    exceeding 10 to 12 weeks size, and absence of adnexal pathology. Infection
    following the previous cesarean was an unfavorable prognostic factor due to an
    increased risk of dense adhesions between the bladder and cervix.


    Another retrospective study compared vaginal hysterectomy outcome of women with
    a history of cesarean (n = 35) to those without this history (n = 186) [14]. Surgical
    indications, number of complications, perioperative hemoglobin change, operative
    time, adjuvant use of laparoscopy, and length of postoperative hospitalization were
    determined for each group. Total complications in the two groups did not differ
    significantly and laparoscopy was only required on the rare occasions in which the
    uterus was adherent to the abdominal wall.


    These studies suggest that a prior cesarean delivery should not be considered a
    contraindication to vaginal hysterectomy.


            Nulliparity — Vaginal hysterectomy outcome in 52 nulliparous and 293
    primiparous or multiparous women was compared prospectively [16]. The mean
    operative time was significantly longer in nulliparous patients (95 versus 80
    minutes), the overall complication rate was significantly higher (13 versus 4
    percent), as was the hemorrhage rate (7.7 versus 1.7 percent). Nevertheless,
    vaginal hysterectomy was successfully performed in 50/52 of the nulliparous and
    292/293 of the parous patients. This suggests that nulliparous women can be
    considered candidates for vaginal hysterectomy.
            Need for oophorectomy — Multiple clinical trials have shown that as many as
    95 percent of ovaries can be removed vaginally, with or without laparoscopic
    assistance [16-23]. Therefore, oophorectomy is not a contraindication to the vaginal
    route.
            Obesity — Exposure of the operative field can be difficult in obese women,
    whether an abdominal or vagina route is taken. The vaginal approach is suggested
for obese women requiring hysterectomy because it can be successfully performed
in this population and is associated with lower postoperative morbidity than
abdominal hysterectomy [24-26].


Summary — In 1999, the Society of Pelvic Reconstructive Surgeons issued
systematic guidelines for selection of hysterectomy route, and excluded some of the
traditional tenets described above (show table 2) [27]. After these guidelines were
issued, a shift to procedures performed by the vaginal route occurred, with
reductions in complications, hospital days, and costs [28,29]. Others have also found
that a policy of encouraging a vaginal approach to hysterectomy results in a high
proportion of hysterectomies successfully performed by this route [30].


We recommend vaginal hysterectomy as the route of choice in most women. This
approach is associated with a more rapid return to normal function compared to
abdominal hysterectomy. In cases with potential extrauterine co-pathology (eg,
endometriosis, pelvic inflammatory disease, adnexal pathology, chronic pelvic pain),
laparoscopy can help to evaluate the abdomen/pelvis and assist in accomplishing
vaginal hysterectomy with or without oophorectomy (see "Laparoscopic assisted
vaginal hysterectomy" below).


However, not all hysterectomies can be or should be approached vaginally. The
tables list contraindications to the vaginal (show table 3) or laparoscopically assisted
vaginal approach (show table 4). Although no specific uterine size is included, the
surgeon must judge whether the access to the blood supply is limited by the uterine
size or pelvic structure.


Laparoscopic assisted vaginal hysterectomy — The use of laparoscopy to
perform hysterectomy is the subject of ongoing debate. Analyzing the role of
laparoscopy is complicated because varying degrees of laparoscopic assistance are
utilized in uterine removal. Surgical procedures described as laparoscopic assisted
vaginal hysterectomy (LAVH) range from a simple diagnostic laparoscopy to rule out
pelvic pathology prior to performing a vaginal hysterectomy to hysterectomy
performed entirely with laparoscopic instruments [31]. The procedure is discussed in
detail separately. (See "Laparoscopic approach to hysterectomy").


The major benefit of laparoscopy prior to hysterectomy is that it provides direct,
panoramic, magnified visualization of the pelvis so the surgeon can assess the
severity of extrauterine pathology (show table 5). The surgeon can use this
information to decide whether this pathology is likely to preclude a vaginal approach
    to hysterectomy under any circumstances or whether additional laparoscopic surgery
    would facilitate vaginal hysterectomy. The surgeon can then proceed vaginally or
    abdominally or perform a vaginal procedure with laparoscopic assistance [29].


    As an example, if laparoscopy reveals moderate adhesions or endometriosis but an
    accessible cul de sac is visualized, the extrauterine impediments can be removed
    laparoscopically prior to proceeding with vaginal hysterectomy [8,32-34]. Additional
    procedures that can be completed laparoscopically to facilitate vaginal hysterectomy
    are management of uterine leiomyomata to facilitate uterine removal and ligation of
    infundibulopelvic ligaments to facilitate difficult ovary removal. In the hands of the
    surgeon facile with laparoscopy, LAVH can used to treat most pathologies, benign
    and malignant, thus making a difficult vaginal hysterectomy easier and avoiding the
    need for open laparotomy [33].


    In addition, laparoscopy is a good option in patients with severe arthritis that
    prohibits proper positioning to allow for adequate vaginal exposure. It allows for an
    appropriate placement of the extremities without patient compromise, while
    providing a minimally invasive approach to hysterectomy [35].


    The laparoscopic route is increasingly being used in management of gynecological
    cancers so these patients may avoid open laparotomy [32,33,36-38]. A vaginal
    approach alone does not allow for evaluation of the abdominal peritoneal surfaces or
    the retroperitoneal lymph nodes to assess for evidence of metastatic disease, but the
    addition of the laparoscopic component overcomes these shortcoming. (See
    "Laparoscopic pelvic and paraaortic lymphadenectomy in gynecologic cancers").


          Contraindications — Contraindications to LAVH are similar to those for
    laparoscopic hysterectomy (show table 4) [34]. A general discussion of the
    contraindications and complications of laparoscopic surgery can be found separately.
    (See "Overview of gynecologic laparoscopic surgery").


    The upper limit of uterine size that would preclude laparoscopic hysterectomy
    depends primarily on the experience of the surgeon, just as with vaginal
    hysterectomy. The ability to access the uterine arteries, rather than an absolute size,
    is another important consideration. In a clinical trial comparing laparoscopic with
    abdominal hysterectomy in patients with leiomyomatous uteri determined to be
    greater than 14 weeks of gestation in size, morbidity was similar for both approaches
    except the laparoscopy group had longer operative times [39].
    High body mass index (BMI) was previously considered a relative contraindication
    due to difficulties in establishing and maintaining the pneumoperitoneum, as well as
    ventilatory challenges with larger women [36]. However, a retrospective study of
    330 patients who underwent total laparoscopic hysterectomy reported that no
    conversions to laparotomy were required on the basis of BMI [36].


    Abdominal versus vaginal versus laparoscopic hysterectomy


          Systematic review — A Cochrane review assessed the most appropriate
    approach to hysterectomy for benign gynecological disease [6]. The review included
    27 randomized trials with a total of 3643 patients. The major findings are listed in
    the table (show table 6); there were wide differences in the reported effects among
    the trials. The authors concluded vaginal hysterectomy should be performed in
    preference to abdominal hysterectomy where possible. When vaginal hysterectomy
    is not possible, they suggested that a laparoscopic approach might avoid the need
    for abdominal hysterectomy; however, the length of the surgery increases as the
    scope of the surgery performed laparoscopically increases and these procedures
    require greater surgical expertise.


    More research needs to be done given the variations in study design, differences in
    outcomes evaluated and surgical expertise, multiple studies with small sample sizes,
    and lack of long-term postoperative evaluation.


          eVALuate trial — The eVALuate trial was a concurrent pair of multicenter
    randomized controlled trials that evaluated the relative roles of vaginal, abdominal,
    and laparoscopic hysterectomy in routine gynecological practice [40]. This trial is the
    largest randomized trial comparing these procedures, and was included in the
    Cochrane review discussed above. The method of randomization was that patients
    were scheduled for abdominal hysterectomy and then randomly assigned to
    laparoscopic or abdominal hysterectomy or else they were scheduled for vaginal
    hysterectomy and then randomly assigned to laparoscopic or vaginal hysterectomy.
    All had benign disease. Women were excluded from participation if they had 2nd or
    3rd degree prolapse, a uterus greater than 12 week size, a medical disorder
    precluding laparoscopic surgery, or if they required bladder or pelvic support
    surgery. The laparoscopic arm included various approaches, including hysterectomy
    where all steps were performed laparoscopically to hysterectomies with vaginal
    surgery components.
The major findings from this trial are shown in the table (show table 7). Although
major composite surgical complications (including conversion to laparotomy)
occurred more frequently in laparoscopic than abdominal hysterectomy, it should be
noted that "conversion to laparotomy" cannot be a complication of abdominal
hysterectomy. Furthermore, conversion to laparotomy is not necessarily a
complication of laparoscopy, but rather a surgical judgment. If only unintended
laparotomies due to a major complication were included in the laparoscopic
hysterectomy group, then the rate of major complications would have been
equivalent for both the abdominal and laparoscopic approaches (7.8 versus 6.2
percent). Another concern regarding these findings are that the surgeons had less
experience with the laparoscopic than the abdominal procedure.


Laparoscopic hysterectomy took longer to perform than abdominal or vaginal
hysterectomy (median time 72 to 84, 50, and 39 minutes, respectively), but was
associated with less postoperative pain than abdominal hysterectomy, as well as a
shorter length of hospitalization (three versus four days), quicker recovery, and
better quality of life six weeks postoperatively.


Results from the vaginal hysterectomy arm were generally favorable, but the sample
size was not large enough to show statistically significant differences between
groups, except for shortest duration of surgery.


A separate cost analysis found that laparoscopic hysterectomy was not cost effective
relative to vaginal hysterectomy, and had comparable cost effectiveness to
abdominal hysterectomy [41]. Observational studies in the United States and Canada
have documented cost effectiveness of laparoscopic hysterectomy as compared to
abdominal hysterectomy based predominately on decreased duration of
hospitalization and quicker return to work [42,43].


Summary — Laparoscopic hysterectomy offers no clinical or economic advantage
over vaginal hysterectomy. It does offer less postoperative pain, shorter hospital
stay and faster convalescence compared to abdominal hysterectomy. It may be
associated with higher risk of urinary tract injury and increased costs. Based on the
discussion above, we suggest vaginal hysterectomy be performed in preference to
abdominal hysterectomy whenever possible because of shorter recovery period and
fewer postoperative infectious complications. We suggest LAVH in patients who
might otherwise require an abdominal hysterectomy. Women whose history and
physical examination suggest that vaginal hysterectomy will be uncomplicated do not
need laparoscopy prior to or during vaginal hysterectomy.
    Total versus subtotal (supracervical) — Some women desire to retain the cervix
    believing that it may affect sexual satisfaction after hysterectomy. It has been
    postulated, without data, that removal of the cervix causes excessive neurologic and
    anatomic disruption, thereby leading to increased operative and postoperative
    morbidity, vaginal shortening, subsequent vault prolapse, abnormal cuff
    granulations, and the potential for fallopian tube prolapse. These issues were
    addressed in a systematic review of total versus subtotal hysterectomy for benign
    gynecological conditions, which reported the following findings [44]:


          There was no difference in the rates of incontinence, constipation or
    measures of sexual function (sexual satisfaction, dyspareunia).
          Length of surgery and amount of blood lost during surgery were significantly
    reduced during subtotal hysterectomy compared to total hysterectomy, but there
    was no difference in transfusion rates.
          Febrile morbidity was less likely and ongoing cyclical vaginal bleeding one
    year after surgery was more likely after subtotal hysterectomy.
          There was no difference in the rates of other complications, recovery from
    surgery, or readmission rates.


    In the short-term, randomized trials have shown that cervical preservation or
    removal does not affect the rate of subsequent pelvic organ prolapse [45,46].
    However, no trials have addressed the risk of pelvic organ prolapse many years after
    surgery, which may differ after total versus supracervical hysterectomy.


    Advantages to supracervical hysterectomy include shorter operative time than total
    abdominal hysterectomy, decreased length of hospital stay if performed
    laparoscopically, and possibly faster convalescence [44-50]. There may also be fewer
    injuries to the urinary tract because the procedure does not dissect as close to the
    cervix or as deep into the pelvis as total hysterectomy. However, clinical trials have
    not been sufficiently powered to demonstrate this clinical observation.


    Other differences include post-hysterectomy body image and health status. In a
    randomized, nonblinded study of women undergoing total abdominal versus subtotal
    hysterectomy, the patients completed questionnaires regarding postoperative quality
    of life, body image, and sexual activity. Women in the subtotal versus the total
    hysterectomy group reported significantly improved body image and health-related
    quality of life [51]. Both groups reported improvements in sexual satisfaction.
The only absolute contraindication to subtotal hysterectomy is the presence of a
malignant or premalignant condition of the uterine corpus or cervix. Extensive
endometriosis is a relative contraindication as these women may have persistence of
dyspareunia if the cervix is retained.


The risks and benefits of retaining the cervix should be included as part of the
preoperative informed consent. We suggest that women should be informed that
retaining the cervix does not appear to confer any medical or sexual benefits.
Although the vagina receives some part of its lubrication from the cervical glands (in
addition to transudate through the vaginal walls), there is no evidence that total
versus subtotal hysterectomy adversely effects vaginal lubrication or leads to
dyspareunia [44,52]. Disadvantages of conserving the cervix includecyclic vaginal
bleeding in some patients (7 to 11 percent [45,53]), the need for routine screening
for cervical cancer, and the potential need for subsequent trachelectomy (eg,
because of bleeding, prolapse, or precancer/cancer) [53]. Thus, on balance, there is
no compelling reason to retain the cervix if it can be easily removed with the corpus.


Elective supracervical hysterectomy should be preceded by cervical cytology
confirming absence of cervical intraepithelial neoplasia. Women who have had a
supracervical hysterectomy should be screened for cervical cancer according to
standard guidelines for their age and risk status. In women with abnormal uterine
bleeding, endometrial cancer should be excluded prior to performing a supracervical
hysterectomy.


Supracervical hysterectomy is indicated for select patients who choose this
procedure after appropriate counseling, and occasionally in surgical emergencies.
Supracervical hysterectomy should not be done because of the surgeon's lack of
comfort with removing the cervix. Instead, assistance from more skilled surgeons
should be sought.


Elective oophorectomy — The risks and benefits of elective oophorectomy at the
time of hysterectomy are discussed in detail elsewhere. (See "Oophorectomy and
ovarian cystectomy" section on Oophorectomy at the time of hysterectomy).


OUTCOME — The outcome of hysterectomy can be assessed in terms of relief of
symptoms, psychosexual issues, and patient satisfaction.


Relief of symptoms — The most common symptoms prior to surgery include
problematic vaginal bleeding, pelvic or back pain, limitation of activity, sleep
    disturbance, fatigue, urinary incontinence, and bloating. One multicenter study of
    1299 women who underwent hysterectomy in Maryland found that at least one of
    these symptoms was present and considered severe in 20 to 70 percent of patients
    preoperatively, but most achieved relief by 24 months postoperatively (show table 8)
    [54]. Ninety-nine percent of patients indicated the surgery had somewhat or
    completely resolved the problems that they had prior to surgery [55], although 8
    percent reported no improvement when surveyed about the specific symptoms
    described in the table [54].


    Psychosexual issues — The majority of retrospective studies on the psychological
    effects of hysterectomy showed an adverse outcome [56]. By comparison,
    prospective studies have found therapeutic effects of hysterectomy, including
    improvement of mood and quality of life. Multiple studies have shown that
    hysterectomy, with or without oophorectomy, appears to have few, if any, effects on
    sexual functioning [52,57-60].


          The Maine Women's Health Study of 418 women showed hysterectomy led to
    marked relief of pelvic pain and vaginal bleeding. There were also modest
    improvements in self-reported feelings of depression, fatigue, sexual dysfunction,
    and other symptoms associated with nonmalignant conditions of the uterus [61]. A
    limited number of women reported new problems such as hot flashes (13 percent),
    weight gain (12 percent), depression (8 percent), anxiety (6 percent), and lack of
    interest in sex (7 percent).
          The Maryland study (discussed above) also noted improvement in the
    proportion of patients reporting depression or anxiety before and after surgery
    (depression 28 versus 12 percent, anxiety 65 versus 25 percent, before and after
    hysterectomy respectively) [54]. In addition, 48 percent of patients described
    limited physical function and 23 percent described limited social function before
    surgery compared to 23 and 5 percent, respectively, 24 months after surgery.


    This study also assessed measures of sexual functioning prior to hysterectomy and at
    6, 12, 18, and 24 months after the procedure [57]. The percentage of women who
    engaged in sexual relations increased from approximately 71 percent before
    hysterectomy to 77 percent at 12 and 24 months after hysterectomy; the rate of
    frequent dyspareunia dropped from 19 to 4 percent; the rate of experiencing
    orgasms increased from 92 to 95 percent; and libido increased. Overall, the
    frequency of sexual activity increased and problems with sexual functioning
    decreased postoperatively.
          A multicenter study from the Netherlands noted no difference in sexual
    function by hysterectomy procedure (abdominal, vaginal, or subtotal) [52]. There
    was a significant increase in sexual pleasure after each of the three procedures.


    A number of confounding factors with the potential to have either a positive or
    negative impact on sexuality, independent of hysterectomy, must be taken into
    account when studying the psychosocial effect of this surgery [62-64]. As an
    example, women with prior psychiatric illness and those with personality and
    psychosocial problems are unlikely to improve after surgery [63]. Other preoperative
    factors reported to increase a woman's emotional distress following hysterectomy
    include a desire to maintain fertility, a high investment in motherhood, and the
    patient who has not dealt well with a previous loss [64].


    Early detection of ovarian failure after hysterectomy and initiation of estrogen
    therapy immediately after surgery in premenopausal women undergoing
    oophorectomy appear to improve the psychological outcome.


    Patient satisfaction — A post-hysterectomy survey in which women were asked to
    what extent the surgical procedure solved their prehysterectomy problems found
    that 85 percent of women were completely satisfied, 11 percent mostly satisfied, 3
    percent somewhat satisfied, and less than one percent were not satisfied [55].
    Overall approximately 70 percent reported much better health after the surgery.
    However, some regret at loss of fertility is common [65].


    Earlier menopause — Hysterectomy appears to impair ovarian function over the
    long-term, at least in some women. One randomized study and several observational
    series have shown that women who undergo hysterectomy develop menopausal
    symptoms earlier than controls not exposed to this surgery, possibly due to
    impairment of the ovarian blood supply [66-71]. In one study, menopause (defined
    as FSH >40) occurred approximately four years earlier in premenopausal women
    who underwent hysterectomy (both ovaries retained) compared to matched controls
    without hysterectomy [71]. Hysterectomy with unilateral oophorectomy was
    associated with an even earlier onset of the menopause.


    COMPLICATIONS — In an Australian population-based study of almost 80,000
    hysterectomies performed for benign indications, the most common complications for
    all surgical approaches combined were: hemorrhage (2.4 percent), genitourinary
    disorders (eg, pelvic organ prolapse, urinary retention, renal or ureteral injury) (1.9
percent), urinary tract infection (1.6 percent), and infection other than in the urinary
tract (1.6 percent) [72].


General complications of hysterectomy are discussed here. Procedure-specific
complications are discussed separately in the topic reviews on each type of
hysterectomy. (See "Abdominal hysterectomy", see "Vaginal hysterectomy", and see
"Laparoscopic approach to hysterectomy").


Urinary incontinence — Hysterectomy may result in damage to the nerve supply
or supportive tissues of the pelvic floor, which may lead to subsequent pelvic floor
dysfunction. The role of hysterectomy in urinary incontinence is controversial [73-
78]. In one large retrospective cohort study (n = 644,766), hysterectomy was
associated with a two-fold increase in risk of subsequent surgery for stress
incontinence compared to women who had not undergone hysterectomy (hazard
ratio 2.4, 95% CI 2.3-2.5). This difference was present regardless of the surgical
approach used for the hysterectomy; women who had previous surgery for stress
urinary incontinence, or for whom the indication for hysterectomy was pelvic organ
prolapse, were excluded [75]. However, this study was limited by the absence of
data on the prevalence of preexisting urinary incontinence symptoms.


Pelvic organ prolapse — Studies have reported discordant findings regarding the
effect of hysterectomy on the development of pelvic organ prolapse [79-82]. The risk
may depend on age, whether prolapse is present at the time of hysterectomy, and
on the surgical approach. However, it is unclear if the increased association of
vaginal hysterectomy with subsequent pelvic organ prolapse is due to selection bias
in performing vaginal hysterectomy or whether the surgical technique is more prone
to cause surgical trauma to the vaginal support tissues.


Potential mechanisms for post-hysterectomy prolapse include alteration in connective
tissue or surgical injury to the innervation and vascularization of the pelvic floor
muscles.


In a large population-based study with the longest period of follow-up (38 years),
the likelihood of undergoing a future pelvic floor repair was significantly higher in
women who had prolapse at the time of hysterectomy (even if a concomitant
prolapse repair was performed) compared with women without prolapse (hazard
ratio 2.5, 95% CI 1.9-3.3) [81]. In addition, for women with prolapse at the time of
hysterectomy, there was a risk of subsequent pelvic floor repair in those who
underwent vaginal, but not abdominal, hysterectomy.
    In a longitudinal study, more than 160,000 women who underwent hysterectomy for
    benign indications were compared with population-based controls and found to have
    a higher risk of subsequent pelvic organ prolapse surgery [83]. Multiparous women
    who underwent vaginal hysterectomy had the highest rate of subsequent prolapse
    surgery, with this risk most evident within five years of hysterectomy.


    INFORMATION FOR PATIENTS — Educational materials on this topic are available
    for patients. (See "Patient information: Abdominal hysterectomy" and see "Patient
    information: Vaginal hysterectomy"). We encourage you to print or e-mail these
    topic reviews, or to refer patients to our public web site,
    www.uptodate.com/patients, which includes these and other topics.


    SUMMARY AND RECOMMENDATIONS


          We recommend a vaginal approach to hysterectomy for most patients
    (Grade 1B). Compared to other routes of hysterectomy, it is less invasive, more
    cosmetic, and associated with fewer complications, shorter hospital stay, lower cost,
    and faster return to normal activity. (See "Abdominal versus vaginal versus
    laparoscopic hysterectomy" above).
          We suggest laparoscopic assisted vaginal hysterectomy in patients in whom
    laparoscopic visualization of the pelvis and laparoscopic surgery are likely to allow
    performance of vaginal hysterectomy and negate the need for laparotomy (Grade
    2B). (See "Laparoscopic assisted vaginal hysterectomy" above).
          We suggest performing total abdominal hysterectomy rather than
    supracervical hysterectomy (Grade 2B). There are no proven medical or surgical
    benefits of performing supracervical or subtotal hysterectomy if the cervix can be
    easily removed with the corpus. We recommend that women who have had a
    supracervical hysterectomy be screened for cervical cancer according to standard
    guidelines for their age and risk status (Grade 1A). (See "Total versus subtotal
    (supracervical)" above).
          After hysterectomy, most women report relief of symptoms, improved quality
    of life, no adverse effect on sexual function, and satisfaction with their surgery. (See
    "Outcome" above).

				
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