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Hysterectomy: Indications

  

Absolute indications for hysterectomy

Uterine fibroma

Uterine fibroma

  • A uterus larger than 14 weeks= more than 800gram.
  • 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 but  leaving endometriosis. Unfortunately this occurs too frequently and generally with an ovariectomy to hide that the endometriosis was not removed

Relative indications for hysterectomy

Endometrium polyp is not an indication for hysterectomy

Endometrium polyp is not an indication 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. A missed or wrong 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.

What is Quality Hysterectomy

Technically Good surgery

  • A short duration of surgery, rarely more than 1 hour.
  • no complications or adhesions
  • a fast recovery
  • also unexpected difficulties as deep endometriosis can be treated
  • an hysterectomy by laparotomy is a complication by definition, since “a complication is  “something unnecessary or avoidable that increases morbidity” “

With the right indication

  • The indications 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 perform too easily an hysterectomy. If your only instrument is a hammer everything looks like a nail
    • an hysterectomy solves all bleeding disorders and cures almost many causes of pelvic pain such as myoma’s, adenomyosis, pelvic varices, a painful retro-version, and even endometriosis pain when the ovaries are removed.
    • With a better diagnosis often alternatives exist which are less invasive, such as hysteroscopic surgery.

 

 

Which technique ?

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
      hysterectomy for myoma

      hysterectomy for myoma

    • 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 ?

[/box]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

NO removal of ovaries

hysteredtomy

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 “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.

Informed consent-medicolegal aspects

hysterectomy rules
Medocolegal correct is a treatment performed by a large number of gynecologist at a certain moment in a certain country.

However, medico-legal correct has no relationship with the best treatment available. Therefore, although a laparoscopic hysterectomy offers many advantages, an hysterectomy by laparotomy remains medico-legal correct,

Informed consent requires 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 than a 3 hour surgery with 20% conversion rate
  • about  ovariectomy  and how other pathology 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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