Hysterectomy
Hysterectomy indications
Absolute indications for hysterectomy
Uterine fibroma
- A uterus larger than 14 weeks, i.e. more than 800 grams.
- A fibroid with complaints such as pain, blood loss and bowel or bladder problems.
- Cancer of the cervix or the uterus
- Total prolapse
What is a mistake?
- Hysterectomy but leaving endometriosis. Unfortunately, this occurs frequently, often an ovariectomy to hide that the endometriosis was not removed
Relative indications for hysterectomy
- Menorrhagia only. If caused by a sub-mucous myoma of a polyp, hysteroscopic surgery is indicated. If no other pathology, menorrhagia can be an indication of endometrial ablation or subtotal hysterectomy.
- 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 is not an indication of a hysterectomy.
- Pelvic pain requires first a diagnosis. A missed or wrong diagnosis is not an indication. Adenomyosis should be used carefully as an indication for a hysterectomy since the diagnosis is rarely certain, and the relationship between adenomyosis and pain is highly variable.
What is Quality Hysterectomy?
Technically good surgery
- A short duration of surgery, i.e. rarely more than 1 hour.
- no complications or adhesions
- a fast recovery
- simultaneous treatment of unexpected pathology as deep endometriosis
- a hysterectomy by laparotomy is a complication by definition, since “a complication is “something unnecessary or avoidable that increases morbidity” “
Too many hysterectomies?
- The wide differences in lifetime risk ( Belgium has a lifetime risk of 35%, 50% in the USA, and 17% in Sweden) cannot be explained by differences in women.
- Some gynaecologists perform too many hysterectomies. If your only instrument is a hammer, everything looks like a nail
- a hysterectomy solves all bleeding disorders and cures many causes of pelvic pain such as myomas, adenomyosis, pelvic varicose veins, and a painful retro-version.
- Often alternatives exist which are less invasive, such as hysteroscopic surgery.
Which technique for 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 a laparoscopic hysterectomy in comparison with an abdominal hysterectomy.
- less pain
- faster recovery
- more cosmetic scar
- For a larger uterus up to 1500 grams a laparoscopic hysterectomy remains possible, but this requires a more experienced surgeon.
Hysterectomy and prolapse
- Our standard approach is a laparoscopic subtotal hysterectomy together with a promontofixation, an intervention of 2.5 hours
- this is not the standard of care since a subtotal hysterectomy + promontofixation in less than 3 hours requires an experienced surgeon
- A vaginal hysterectomy is a classic surgery with a 30% recurrence rate.
Total or subtotal hysterectomy?
]Considering that the cervix of the uterus is richly innervated and fixed in the pelvic floor, it is logical to anticipate that a subtotal hysterectomy will be associated with
- less postoperative pain and a faster recovery
- better sexual life 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
NO removal of ovaries during hysterectomy
- 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 the “tradition” of oncologists and gynaecologists’ “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 gynaecologists remove fewer ovaries than men.
Informed consent and medicolegal aspects
Medicolegal correct is a treatment performed by most gynaecologists at a certain moment
This is not necessarily the best treatment available.
Informed consent requires the correct information
- about the diagnosis
- about the advantages of a laparoscopic hysterectomy
- about the skills and results of the surgeon: a 45 min hysterectomy is not the same intervention as a 3-hour surgery with a 20% conversion rate
- about ovariectomy and how other pathology, such as deep endometriosis, which can be an accidental finding, will be handled, especially when too difficult for the surgeon. An ovariectomy while leaving the endometriosis is wrong.
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