Hysterectomy in Gynecology
Absolute indications for hysterectomy
- A uterus larger than 14 weeks= more than 1 kilo.
- A fibroid with complaints as pain, blood loss and bowel or bladder problems.
- Cancer of the cervix or the uterus
- Total prolapse
What is always wrong ?
- Hysterectomy and leaving endometriosis. Unfortunately this occurs too frequently
Relative indications for hysterectomy
- Menorrhagia only. If the uterus is normal and without any other pathology menorrhagia is an indication for an endometrial ablation or subtotal hysterectomy. If the cause is a sub-mucous myoma of a polyp, this should be treated by hysteroscopy.
- Irregular bleeding often is induced by hormonal treatment such as oral contraception (7%), a continuous combined therapy after menopause or progestagens only (Mirena, Lutenyl, Orgametril). This obvious is not an indication for an hysterectomy.
- Pelvic pain : first a diagnosis then a therapy ! To miss a diagnosis is not an indication. Adenomyosis should be used carefully as an indication for hysterectomy since the diagnosis is generally not that certain, and since the relationship between adenomyosis and pain is highly variable. Too often the potential diagnosis of adenomyosis is used as an alibi to perform an hysterectomy.
Laparoscopic hysterectomy is the standard since 1996
- We always perform Laparoscopic Hysterectomy for a uterus less than 1 kilo. because of the many advantages of the laparoscopic hysterectomy in comparison with an abdominal hysterectomy.
- less pain
- faster recovery
- more cosmetic scar
- For a bigger uterus at least up to 1500 gram is a laparoscopic hysterectomy is generally possible, but this has to be discussed individually.
Also for a prolapse
- Our standard approach is a laparoscopic subtotal hysterectomy together with a promontofixation
- this is an intervention of 2.5 hours
- this is not the general standard of care : to do a subtotal hysterectomy+promontofixation in less than 3 hours requires an experienced surgeon
- A vaginal hysterectomy is the classic option but the recurrence rate is over 30%.
Total or subtotal hysterectomy ?
Considering that the cervix of the uterus is richly innervated and fixed in the pelvic floor, it is logic to anticipate that a subtotal hysterectomy will be associated with
- less postoperative pain and a faster recovery
- better sexual live afterwards
- less prolapse later
- This has not yet been proven in RCT, since only experienced surgeons will be able to demonstrate the differences
- Morcellation has to be discussed with the patient
- This is no longer controversial since women with ovaries live longer than women without.
- notwithstanding the risk of 1/200 of an ovarian cancer
- ultrasound permits an adequate screening
- in addition ovaries after menopause still produce hormones,
- with a better quality of life
- especially androgens which are difficult to replace during hormone replacement therapy .
- in younger women endometriosis is not an absolute indication of ovariectomy
- Why so many ovaries are still removed : it remains “tradition” of oncologists and gynecologists “old style”.
- this was reasonable when all surgery was performed by laparotomy, and ovaries were removed in order to prevent a second intervention,;
- A non scientific argument is the observation that woman gynaecologist remove less ovaries than men.
- A short duration of surgery i.e. less than 1 hour.
- without complications or adhesions
- a fast recovery
- unexpected difficulties as deep endometriosis can be dealt with .
If a complication is defined as “something unnecessary or avoidable that increases morbidity” then an hysterectomy by laparotomy is a complication by definition
No unnecessary interventions
- The indications vary with the country and vary with the gynaecologist. The wide differences in life time risk ( Belgium has a life time risk of 35%, 50% in USA, 17% in Sweden) cannot be explained by differences in women.
- Some gynaecologist easily perform an hysterectomy ; others have more restraint.
- The problem is that an hysterectomy indeed solves all bleeding disorders and it cures almost all causes of pelvic pain such as myoma’s, adenomyosis, pelvic varices, a painful retroversion, and even deep endometriosis when the ovaries are removed. Often it is performed together with other surgery such as pelvic floor repair. With a better diagnosis often alternatives exist which are less invasive, such as hysteroscopic surgery. Moreover the introduction of laparoscopic surgery introduced other better techniques : important is to choose the best technique for the individual patient