Gynaecologists are often criticised by women's groups for performing too many total hysterectomies, by other gynaecologists for performing too few vaginal hysterectomies, and by laparoscopic surgeons for performing too few laparoscopic hysterectomies. The traditional abdominal hysterectomy is therefore a much oppressed, even maligned, operation. Subtotal hysterectomy is being strongly advocated in order to preserve sexual function and prevent post-operative urinary symptoms; however Ayman Ewies and Karl Olah (pages 1376–1379) question the current fashion for this procedure. The authors carried out a retrospective analysis of 150 women who underwent subtotal hysterectomy, 60 of whom chose this method because of its perceived benefits. One in eight of the women required further treatment because of long-term problems with the cervical stump; in one in twelve of the women this problem was menstruation, the very complaint which most commonly resulted in the hysterectomy in the first place. In six women vaginal trachelectomy was performed, a formidable procedure if the subtotal hysterectomy was unavoidable owing to endometriosis; and five women underwent large loop excision of the transformation zone. Five women developed genuine stress incontinence. The authors suggest that the supposed sexual and urinary benefits of subtotal hysterectomy are not proved, and that a randomised trial is required to compare total with subtotal hysterectomy.
Christian Ottosen and colleagues (pages 1380–1385) performed a randomised trial in 120 women with benign conditions of the uterus to compare total abdominal hysterectomy, vaginal hysterectomy and laparoscopic-assisted vaginal hysterectomy. The duration of surgery and of anaesthesia were longest with laparoscopic-assisted vaginal hysterectomy, while the length of stay in hospital and the time to recovery were longest with abdominal hysterectomy. The results are very much in favour of vaginal hysterectomy, for not only was the length of stay in hospital the shortest, half of the laparoscopic-assisted vaginal hysterectomies underwent laparoscopic inspection only before the vaginal part of the procedure.
Mary Ann Lumsden and her colleagues (pages 1386–1391) went further in their randomised trial, by investigating the women's perceptions of their hysterectomy. The authors compared total abdominal hysterectomy and laparoscopic-assisted vaginal hysterectomy. The duration of the operation was shorter with abdominal hysterectomy but the length of stay in hospital longer; an economic analysis showed that abdominal hysterectomy was cheaper. After the operation there was no difference in measurements of the quality of life.
These papers suggest that vaginal hysterectomy is the preferred procedure for benign uterine conditions, but traditional abdominal hysterectomy is no bad operation. It may be important to a hospital manager if a woman stays in hospital two days longer after an abdominal hysterectomy, but it may not matter to the woman. It may be important to her employer that she takes a week longer to go back to work, but it may not matter to the woman. Besides, difficulties encountered at vaginal hysterectomy or laparoscopic-assisted vaginal hysterectomy are treated by abdominal hysterectomy. Abdominal hysterectomy is here to stay; the main question is, should it be total or subtotal?