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The paper by Lieng et al. in this issue of BJOG1 raises again the question of should the cervix be removed as a routine part of hysterectomy? This clinical conundrum is reflected by the uncertainty in the terminology used for this approach. Many gynaecologists use the term subtotal with subliminal implications of a substandard or incomplete procedure, while others use the alternative supracervical with its connotations of being a superior and improved technique.

The world’s first successful, planned subtotal abdominal hysterectomy was performed on 1 September 1853 by Gilman Kimball in Massachusetts, USA, and the first successful planned subtotal in Europe was undertaken by Charles Clay in Manchester about 10 years later.2 From this time until the present day, the subtotal/supracervical approach has enjoyed cycles of popularity with various advantages and disadvantages being periodically highlighted by proponents and opponents alike. In the early days of hysterectomy, the subtotal approach dominated. This cervix-sparing approach is undoubtedly technically simpler than total abdominal hysterectomy (TAH) and avoids the need for dissection through the highly vascular paravaginal cuff in close proximity to the ureter. It remains an entirely intraperitoneal procedure and avoids communication between the potentially contaminated vagina and the abdominal cavity. It has long been suggested that these direct consequences of the approach are associated with clinical benefits. Despite such potential benefits, TAH progressively became the default hysterectomy procedure as surgical equipment and techniques improved. Total hysterectomy was considered the preferred operation because it removed the whole uterus intact and thereby substantially reduced the risk of cervical malignancy and avoided the possibility of persistent vaginal bleeding. More recently, there has been a swing back to subtotal, but the magnitude of this has varied markedly between countries. The proportion of subtotal hysterectomies in Denmark rose by about 458% between 1988 and 1998, by which time 22% of all hysterectomies were subtotal.3 Similarly, there has been a rise in proportion of subtotals performed in the USA from 0.7% in 1990 to 1.1% in 19934 and subsequently to 1.6% in 1997 and 7.5% in 2004.5 These changes in method were more pronounced in California where the rate was 6.9% in 1994 and rose to 20.8% in 2003.6 In all Scandinavian countries, the ratio of STH to TAH is high and in Sweden, for example, the ratio is 0.56. In contrast, the rate in the UK remains very low with a ratio of only 0.04.7

Suggested reasons to remove the cervix

  1. Top of page
  2. Suggested reasons to remove the cervix
  3. Suggested reasons for retaining the cervix
  4. The effect of laparoscopic approach on outcomes after subtotal hysterectomy
  5. Author’s conclusions
  6. References

Cancer in the residual cervical stump

The most feared complication associated with retention of the cervix is the subsequent development of cancer in the stump. This risk was real. In a French series of 1787 women treated for cervical carcinoma between 1950 and 1961, about 173 (10%) developed the cancer in a retained cervical stump.8 In a series of cervical cancers from the Radiumhemmet, Sweden, treated between 1959 and 1987, about 145 (2.2%) of the total had cancer that developed from a cervical stump,9 and in a Brazilian series, 3.85% of a series of 363 cases collected over 15 years had cancer developing in the cervical stump.10 It is the magnitude of this severe potential complication that prompted the near universal adoption of total hysterectomy as the default operation for benign gynaecological disorders for much of the 20th century. It is important to recognise that most of these cases occurred before the introduction of cervical cytology. There are no data about the risk of developing stump cancer in women who are appropriate screened, but it is presumed to be extremely low. There would therefore appear to be little or no indication to remove the cervix as a prophylactic measure to prevent cervical cancer in women who are in an adequate cytological screening programme. There is, however, a small theoretical risk of developing endometrial cancer and various sarcomas in the residual cervical stump. Data on the frequency of these events are very limited, but the possibility of endometrial cancer should be born in mind when advising women on the use of subsequent hormone replacement therapy

Postsurgical vaginal bleeding

The other major disadvantage of retaining the cervix is the risk of continuing cyclical vaginal bleeding. In a meta-analysis of this topic, 11.4% of 687 women presented with some element of cyclical menstrual bleeding after STH,7 and in the series reported in this issue by Lieng et al., about 24% of 240 women reported some degree of persistent bleeding but only 8% bled cyclically. In the Cochrane review comparing these two procedures,11 the risk of persistent bleeding after subtotal compared with total hysterectomy was 2.1 [odds ratio (OR) 1.02–4.3]. Most of those with post-bleeding were not troubled by the symptom, and only 7% of women with bleeding required further surgery. Nonetheless, in a small proportion of women, this bleeding represented a significant disadvantage to the retention of the cervix. The risk of persistent bleeding after hysterectomy appears to be related to surgical experience with a higher incidence being observed in procedures undertaken by less experienced surgeons.

Risk of persisting symptoms

Okaro et al.12 reported that 24.3% of 70 consecutive women undergoing laparoscopic supracervical hysterectomy reported symptoms related to the cervical stump that required further surgery and removal of the cervix, of which 4 had histological evidence of persistent endometriosis. This study was an early study of the laparoscopic approach and may reflect relative inexperience in adequately removing the whole of the corpus, but it still serves to warn that symptoms may persist if the corpus is inadequately excised particularly in the presence of endometriosis. Lieng et al.1 pointed out that the mean pain score after STH in women undergoing hysterectomy for endometriosis was significantly higher (ps = 3.46) compared with those in whom the surgical indication was fibroids (ps = 1.08, P < 0.01). Donnez et al.13 report the rare complication of what they term ‘Iatrogenic adenomyosis’ in 0.56% of a very large series of laparoscopic subtotal hysterectomies (n= 1633). This complication was not observed in a similar large number of women having laparoscopic assisted vaginal hysterectomies. It thus appears that for women with endometriosis, there is a greater risk of persisting pain and endometriosis after subtotal than after other forms of hysterectomy.

Suggested reasons for retaining the cervix

  1. Top of page
  2. Suggested reasons to remove the cervix
  3. Suggested reasons for retaining the cervix
  4. The effect of laparoscopic approach on outcomes after subtotal hysterectomy
  5. Author’s conclusions
  6. References

More rapid and safer surgery

These factors have been investigated in three randomised trials, one each from the UK,14 Denmark15 and the USA,16 and these studies have been collated in a Cochrane review.11 In the UK trial, the STH operation was significantly shorter (59.5 versus 71.1 minutes, P < 0.001) and the amount of blood loss was significantly less (320.1 versus 422.6 ml, P= 0.004) than in the TAH arm. In the Swedish trial, similar but nonsignificant trends were observed, and in the USA trial, there were no differences in short-term surgical outcomes except that the risk of febrile morbidity overall was less in the STH group (OR = 0.43, 0.25–0.75). There was no evidence of differences in the rates of other complications or readmission rates.

Improved sexual function after hysterectomy

Hysterectomy inevitably disrupts the nerve supply and anatomical relationships of the pelvic organs. It has been suggested that as STH hysterectomy may result in less pelvic nerve plexus damage it consequently lessens postoperative sexual dysfunction. This suggestion was supported by a randomised trial17 that attracted wide public attention and led many women to request ‘the hysterectomy that better preserved sexual function’. The methodology of the trial was, however, suspect, and the results have not been confirmed by several other more rigorous studies.18–20 Each of these studies report that the majority of women experience no negative impact on sexual satisfaction after abdominal hysterectomy whatever the method undertaken and that there is no measurable benefit associated with the subtotal approach.

Improved bowel and bladder function after hysterectomy

As the subtotal approach minimises anatomical disruption, it has also been suggested that STH is likely to have less adverse effects on bowel and bladder function after surgery. Three randomised clinical trials (RCTs) looked at urinary function after TAH and STH.14–16 In two of the studies, there was no difference between the incidence of urinary incontinence in the two trial arm; and in the other trial, surprisingly, a smaller proportion of women suffered urinary incontinence after TAH than STH at 1 year after surgery (9 versus 18%; OR = 2.08, 1.01–4.29).15 The Thakar study also investigated the frequency of bowel symptoms as indicated by the report of constipation and the use of laxatives and found no difference between the groups.

The effect of laparoscopic approach on outcomes after subtotal hysterectomy

  1. Top of page
  2. Suggested reasons to remove the cervix
  3. Suggested reasons for retaining the cervix
  4. The effect of laparoscopic approach on outcomes after subtotal hysterectomy
  5. Author’s conclusions
  6. References

Most of the studies reported above were comparing open laparotomy subtotal and total hysterectomy. The development of laparoscopic approaches to hysterectomy over the last decade was perhaps the most important stimulus to the renewed interest in this approach. The short-term advantages of the laparoscopic approach to hysterectomy have now been well documented and include less operative pain, shorter convalescent time, quicker return to full activity and more rapid improvement in short-term quality-of-life measures.21 It was argued that these benefits may be even more apparent with laparoscopic subtotal hysterectomy. Some of the most influential gynaecological laparoscopic surgeons have championed this proposition,22–24 and each have demonstrated rapid recovery and low complication rates. Initially, one of the downside of the laparoscopic approach was the considerably increased operating time. Improvements in technology including improved mechanical morcellators, the use of Plasma Kinetic energy for blood vessel sealing and the ‘Lap Loop’ system for speedy amputation of the cervix has resulted in a reduction of the operating time to around 45 minutes.25 The comparative benefits of laparoscopic total and subtotal hysterectomy have been tested in a single RCT of 141 women.26 They observed no significant differences in complication rates or clinical outcomes during a 2-year follow up except that women undergoing subtotal laparoscopic hysterectomy (SLH) tended to have more hospital readmissions than those randomised to total laparoscopic hysterectomy (TLH).

Author’s conclusions

  1. Top of page
  2. Suggested reasons to remove the cervix
  3. Suggested reasons for retaining the cervix
  4. The effect of laparoscopic approach on outcomes after subtotal hysterectomy
  5. Author’s conclusions
  6. References

The advantages of the subtotal approach to hysterectomy appear confined to the perioperative period. With the open procedure, the operative time is shorter, and with both open and laparoscopic subtotal hysterectomies, there is less blood loss and less febrile morbidity. These benefits may be associated with a more rapid improvement in short-term quality-of-life measures, and these benefits may be greater after the laparoscopic approach, but this has not yet been confirmed in adequately sized randomised trials.

There appear to be no long-term benefits associated with retention of the cervix, and there are some important negative consequences. Regular post-STH cervical screening is required, and there are risks of continual vaginal bleeding and postoperative pain particularly if the procedure is associated with endometriosis. These disadvantages are not offset, as had previously been claimed, by any observed improvement in sexual, bowel or bladder function.

The evidence currently suggests that women should be advised that subtotal or supracervical hysterectomy may be associated with less perioperative problems and a quicker return to normal activities particularly after laparoscopic procedures. These worthwhile gains are offset by evidence, suggesting an increased risk of persistent bleeding, pain and repeat surgery and the definite need for continued cytological screening. They should also be advised that there are no obvious long-term benefits in retaining the cervix in terms of sexual, bladder, bowel or bladder function, but the effects on long-term quality-of-life measures has not yet been determined by appropriate trials.

Given the benefit of rapid recovery after surgery associated with the less morbid subtotal hysterectomy, it would be useful to conduct appropriately designed RCTs of subtotal hysterectomy against nonsurgical interventions such as Mirena and also against low morbidity modern endometrial ablation techniques. The benefits of the laparoscopic approach compared with the open procedure have been suggested by some large retrospective series, but a properly established RCT may well define one of the most potentially rewarding laparoscopic approaches. There remain many unanswered questions regarding the optimum method of performing hysterectomy, but recent data have dispelled some myths and clarified the indications for the different approaches.

References

  1. Top of page
  2. Suggested reasons to remove the cervix
  3. Suggested reasons for retaining the cervix
  4. The effect of laparoscopic approach on outcomes after subtotal hysterectomy
  5. Author’s conclusions
  6. References