You are in: eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery HysterectomyArticle Last Updated: Aug 22, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Hetal B Gor, MD, FACOG, Consulting Staff, Private Practice, Bergen County, New Jersey Hetal Gor is a member of the following medical societies: American College of Obstetricians and Gynecologists Coauthor(s): Gloria Bachmann, MD, Associate Dean of Women's Health, Women's Health Institute, Departments of Medicine and Obstetrics and Gynecology, Chief of Obstetrics and Gynecology Service, Professor, Robert Wood Johnson University Hospital, UMDNJ; Sagar Patel, BS, Robert Wood Johnson Medical School-UMDNJ Editors: Andrea Witlin, DO, PhD, Former Assistant Professor, Department of Obstetrics and Gynecology, University of Texas Medical Branch; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University; Chief, Division of Reproductive Genetics, Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern Memorial Hospital Author and Editor Disclosure Synonyms and related keywords: uterine disease, gynecologic dysfunction, sterility, total abdominal hysterectomy, TAH, fibroids, leiomyomas, benign uterine tumor, endometriosis, genital prolapse, uterine prolapse, pelvic relaxation, uterine cancer, uterus cancer, endometrial cancer, cervical cancer, cervix cancer, radical hysterectomy, vaginectomy INTRODUCTIONSection 2 of 10
  Hysterectomy is the most common non–pregnancy-related major surgery performed on women in the United States. This surgical procedure involves removal of the uterus and cervix, and for some conditions, the fallopian tubes and ovaries. Reasons for choosing this operation are treatment of uterine cancer and various common noncancerous uterine conditions that lead to disabling levels of pain, discomfort, uterine bleeding, and emotional stress. Although this procedure is highly successful in curing the disease of concern, it is a surgical alternative with the accompanying risks, morbidity, and mortality that an operative procedure carries and it leads to sterility in women who are premenopausal. The patient may be hospitalized for several days and may require 6-12 weeks of convalescence. Complications such as excessive bleeding, infection, and injury to adjacent organs also may occur. History of the ProcedureIn November 1843, Charles Clay performed the first hysterectomy in Manchester, England. In 1929, Richardson, MD, performed the first total abdominal hysterectomy (TAH), in which the entire uterus and cervix were removed (Johns, 1997). ProblemEpidemiology of fibroids Fibroids, or leiomyomas, account for one third of hysterectomies and one fifth of gynecological visits, and they create an annual cost of $1.2 billion (Lepine, 1997; Zhao, 1999). They are benign uterine tumors that increase in size and frequency as women age but revert in size postmenopausally (Goodwin, 2001; Kjerulff, 1996). Factors that have proven to contribute to fibroid growth include estrogen, progesterone, insulinlike growth factors I and II, epidermal growth factor, and transforming growth factor-beta (Guarnaccia, 2001). The frequency of fibroid appearance in African American women is 2-3 times higher than in white women. Women who are obese or experience menarche when younger than 12 years are at increased risk of fibroid development due to prolonged exposure to estrogen. Women who have had children are at a lesser risk for fibroid development than women who have never been pregnant (Demello, 2001). Each fibroid arises from a single monoclonal cell line from the smooth-muscle cells of the myometrium (Townsend, 1970). Most (60%) fibroids are chromosomally normal. The rest have nonrandom chromosomal abnormalities that can be separated into 6 cytogenic subgroups, which are trisomy 12, translocation between chromosome 12 and 14, rearrangements of the short arm of chromosome 6 and the long arm of chromosome 10, and deletions of chromosomes 3 and 7 (Gross, 2001). Asymptomatic fibroids are relatively slow growing and characterize most of the tumors found in patients. Previously, uterine size (consisting of asymptomatic fibroids) equivalent to 12 weeks' gestation (280 g) had been the standard threshold for recommending a hysterectomy. Thus, asymptomatic fibroids of smaller size were handled via observation, with an annual pelvic examination and/or transvaginal ultrasound. Currently, surgical procedures are not recommended for fibroids based on uterine size alone in the absence of symptoms. According to Reiter et al (1992), no increased incidence in perioperative morbidity existed posthysterectomy in those women with a fibroid uterus larger than 12 weeks' gestational size compared to those women with a fibroid uterus smaller than 12 weeks' gestational size. They concluded that hysterectomy for a large asymptomatic fibroid uterus may not be needed as a means of preventing increased operative morbidity associated with future growth, unless a sarcomatous change is observed. In patients who experience symptoms with fibroids, the symptoms are related to the size, location, and number of fibroids within the uterus. As many as one third of patients with symptomatic uterine fibroids experience abnormal bleeding, cramping, and prolonged and heavy menstrual periods, which can result in anemia. The growth of fibroids to large sizes may cause pressure on local organs; thus, presenting symptoms may include pelvic pain or pressure, pain during sexual intercourse, reduced urinary capacity due to increased bladder pressure, constipation due to increased colon pressure, and infertility or late miscarriages (Guarnaccia, 2001). Epidemiology of endometriosis Endometriosis is responsible for approximately one fifth of hysterectomies, and it affects women during their reproductive years (Lee, 1984). It is a disease in which tissue similar to the endometrium is present outside the endometrial cavity (in other areas of the body). Such sites include all the reproductive organs, bladder, intestines, bowel, colon, and rectum. Other sites may include uterosacral ligaments, the cul-de-sac, pelvic sidewalls, and surgical scars. This ectopic endometrial tissue responds to monthly hormonal stimulation and, thus, breaks down and bleeds into the peritoneal cavity when located there, causing internal bleeding, inflammation of the surrounding areas, and formation of scar tissue. Scar tissue then can become bands of adhesions that are capable of distorting internal anatomy. Patients also may experience symptoms of pelvic pain; pain during bowel movements, urination, and sexual intercourse; and infertility or miscarriages (Weir, 2001). Currently, no cure exists for endometriosis. Although many women seek hysterectomy for pain relief, it does not provide a definite cure because some women in whom one or both ovaries are preserved may continue to experience problems with endometriosis that was left behind. Epidemiology of pelvic relaxation Genital prolapse is the indication for approximately 15% of hysterectomies. Various stresses on the pelvic muscles and ligaments can cause significant weakening and, thus, uterine prolapse. The prime cause of insult to the pelvic support structures is childbirth. Therefore, multiple pregnancies and vaginal deliveries increase the risk for uterine prolapse. A few less dramatic causes of increased pelvic pressure include straining during bowel movements, chronic coughing, and obesity. Also, significant pelvic structure weakening occurs postmenopause because estrogen, which pelvic tissues need to maintain their tonicity, is not present in significant amounts after menopause. Women with mild pelvic relaxation may be free of symptoms. However, patients with moderate-to-severe relaxation may experience symptoms that include heaviness and pressure in the vaginal area; low back pain, leakage of urine, which can worsen during heavy lifting, coughing, laughing, or sneezing; urinary tract infections; and problems with sexual intercourse (Lee, 1984). Although several techniques that provide temporary improvement and control of pelvic relaxation exist, in moderate-to-severe situations, hysterectomy may provide a more functional and longer-lasting result and even may prevent the need for a second operation in case prolapse symptoms worsen later with the development of cystocele and/or rectocele. Epidemiology of cancer of reproductive organs Cancer of the uterus, or endometrial cancer, is the most common gynecological cancer in the United States, with an estimated 36,100 new cases in 2000 (Greenlee, 2000). It affects women aged 35-90 years, with a mean age of 62 years. Cancer begins in the lining of the endometrium and can spread to other reproductive organs and to the rest of the body. Stage 1 endometrial cancer is confined to the corpus, or body, of the uterus. Symptoms may include bleeding between periods or, as is in most cases, spotting in patients after menopause. Stage 1 endometrial cancer is very slow growing and highly curable. A hysterectomy is the preferred method of treatment. Not only is the uterus removed, but the ovaries and fallopian tubes also are removed because ovaries are a possible site for more cancer, or they may secrete hormones that play a synergistic role in the growth of the cancer. Only in rare cases of early endometrial cancers in women who are in their second or early part of the third decade of life are attempts made to preserve the ovaries. In stage 2 endometrial cancer, the cancer has spread to the cervix. Approximately 12,800 new cases of cervical cancer diagnoses occur annually in the United States (Sawaya, 2001). Symptoms of cervical cancer include bleeding between periods, bleeding postmenopause, or bleeding after sexual intercourse. In some cases, radical hysterectomy (removal of the uterus, cervix, top portion of vagina, ovaries, fallopian tubes, and tissues in the pelvic cavity surrounding cervix) may be the treatment of choice, along with chemotherapy or radiotherapy if needed. In stage 3A endometrial cancer, the cancer has spread to the ovaries and fallopian tubes. This may be treated with a TAH and bilateral salpingo-oophorectomy (removal of the uterus, fallopian tubes, and ovaries), along with chemotherapy or radiotherapy if needed. In stage 3B, the cancer has spread to the vagina. In this case, a vaginectomy or radical hysterectomy must be performed, along with chemotherapy or radiotherapy if needed. By stage 3C, the cancer has entered the lymph nodes. In this case, lymph node dissection and hysterectomy is the treatment of choice, along with chemotherapy or radiotherapy if needed. FrequencyApproximately 600,000 hysterectomies are performed annually in the United States, with a cost of approximately $5 billion per year. The US Centers for Disease Control and Prevention (CDC) estimated 8.6 million US women had a hysterectomy from 1980-1993. During this span, the CDC studied how the rates of hysterectomy differed by age, geographic region, and conditions associated with hysterectomy. Annually, the rates were highest among women aged 40-44 years and lowest among women aged 15-24 years. Each year, the highest rate of hysterectomies was in the South, with an incidence of 6.8 cases per 1000 population, while in the Northeast, Midwest, and West, the rates were 3.9, 5.5, and 4.9 cases per 1000 population, respectively (Lepine, 1997). The most common medical reasons for undergoing a hysterectomy include benign fibroid tumors, dysfunctional uterine bleeding (DUB), endometriosis, and uterine prolapse. Uterine cancer is not as common but is an important reason for undergoing a hysterectomy. ClinicalPreoperative evaluation includes the following:
INDICATIONSSection 3 of 10
Reasons for choosing hysterectomy are treatment of uterine cancer and various common noncancerous uterine conditions that lead to disabling levels of pain, discomfort, uterine bleeding, and emotional stress. RELEVANT ANATOMYSection 4 of 10
CONTRAINDICATIONSSection 5 of 10
Vaginal hysterectomy is contraindicated in only 10-20% of cases, eg, uterine size greater than 280 g (Kovac, 1997), previous multiple abdominal or pelvic surgeries, advanced uterine or cervical malignancies, and ovarian malignancies. WORKUPSection 6 of 10
Lab Studies
TREATMENTSection 7 of 10
Medical therapyAlthough hysterectomy often is the definitive treatment for many pelvic pathologies, nonsurgical alternatives always should be attempted in elective cases. Hormonal therapy, gonadotropin-releasing hormone antagonists, IUD-containing progesterone, endometrial ablation, focused ultrasonographic surgery, cryotherapy, and uterine artery embolization have been used with success. Surgical therapyAbdominal hysterectomy In November 1843, Charles Clay performed the first hysterectomy in Manchester, England. The earliest hysterectomies were supracervical, or subtotal, hysterectomies. The body of the uterus was removed while the cervix remained intact. In 1929, Richardson, MD, performed the first TAH, in which the entire uterus was removed (Johns, 1997). Prior to an abdominal hysterectomy, the patient undergoes a regional or general anesthetic. A patient remains awake during a regional anesthetic, with only part of the body being numbed to prevent pain. When given a general anesthetic, the patient is unconscious. The abdominal hysterectomy begins via a surgical incision 6-8 inches long, made either vertically, running from the navel to the pubic bone, or horizontally, running along the top of the pubic hairline. The cut exposes the ligaments and blood vessels surrounding the uterus. These ligaments and blood vessels then are separated from the uterus and cervix. In the process, the blood vessels are tied off to prevent bleeding and to help in healing. The uterus and cervix are then cut off at the superior portion of the vagina and removed. The top of the vaginal cuff is closed with sutures, and the surgical wound is closed in layers. An abdominal hysterectomy may be performed in conjunction with a salpingo-oophorectomy, in which the adnexa are removed, if needed. Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; or urinary tract infection. Candidates for this surgery include those who have fibroids, abnormal or heavy bleeding, chronic pelvic pain, endometriosis, adenomyosis (endometrial tissue that has infiltrated the myometrium), uterine prolapse, cancer of the reproductive organs, or pelvic inflammatory disease. Vaginal hysterectomy In a vaginal hysterectomy, the uterus is removed through the vaginal introitus. Prior to surgery, the patient is given a regional or a general anesthetic and the skin surrounding the vagina is prepped with an antibacterial solution. A surgical incision is then made in circular fashion around the cervix and through the upper vagina to expose the tissue and blood vessels around the cervix and uterus. The tissues and vessels are cut and tied off for the uterus and cervix to be removed from the top of the vagina. The upper part of the vagina where the surgical incision was made then is sutured. Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; or urinary tract infection. Often, colporrhaphy (reconstructive surgery) is done to repair or prevent cystocele, rectocele, and/or vaginal vault prolapse. Candidates for this surgery include those who have fibroids, abnormal or heavy bleeding, adenomyosis, uterine prolapse, early-stage cancer of the reproductive organs, or precancerous conditions of reproductive organs. Laparoscopically assisted vaginal hysterectomy Laparoscopically assisted vaginal hysterectomy (LAVH) is a procedure that uses laparoscopic surgical techniques and instruments to remove the uterus, cervix, and/or fallopian tubes and ovaries through the vagina. Prior to surgery, the patient is usually given a general anesthetic and the abdomen and vagina are prepared with an antibacterial solution. LAVH begins with several small abdominal incisions inferior to the belly button, which allow the insertion of the laparoscope and other surgical tools. In order for the surgeon to observe the inside of the body clearly, the peritoneal cavity is inflated with gas (usually carbon dioxide), and a camera, which is attached to the laparoscope, captures and produces a continuous image that is magnified and projected onto a television screen. Using the laparoscopic surgical tools, the tissues and vessels surrounding the uterus are cut and tied off. The uterus and cervix then is removed through the vagina, and the top of the vaginal cuff is sutured. The fallopian tubes and ovaries also may be removed during this surgical procedure. Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; or urinary tract infection. Candidates for this surgery include those who have had previous abdominal surgery, large fibroids, chronic pelvic pain, endometriosis, or pelvic inflammatory disease, or those who want an oophorectomy. Today, robotic laparoscopic surgery, such as procedures involving the da Vinci Surgical Robot, also is being refined to evaluate the performance of LAVH. Comparisons of hysterectomy procedures With the various hysterectomy procedures available, physicians must limit health care dollars associated with these surgical procedures while maintaining quality health care for patients. Various studies have been performed to decide which surgical procedure is most suitable in terms of economics and patient health. In a study provided by Carter et al (1994), patients undergoing LAVH were compared to patients undergoing TAH. Patients in both categories shared similar demographics, pathological diagnoses, and a common symptom of severe disabling pelvic pain. Results of the study showed that operative time for LAVH (144 ± 31 min) was significantly longer than for TAH (98 ± 50 min). No significant difference in blood loss occurred between the 2 groups, with patients who underwent LAVH losing 216 ± 82 mL compared to patients who underwent TAH and lost 299 ± 31 mL. The length of stay for patients in the LAVH group (2.125 ± 0.875 d) was significantly shorter than for patients in the TAH group (3.54 ± 0.96 d). Postoperative pain levels also were measured on a 10-point activity scale, with 1 equal to no pain and 10 equal to unbearable pain. On day 1, no significant difference between LAVH (6.6) and TAH (6.4) was noted. However, on day 7, pain with LAVH (2.8) was significantly less than with TAH (3.6), and, by week 3, LAVH (1.46) continued to produce significantly less pain than TAH (1.8). Postoperative activity levels also were measured on a 10-point activity scale, with 1 equal to extremely limited activity and 10 equal to no limits on activity. On day 1, no significant difference between LAVH (3.4) and TAH (3.3) activity levels was noted. However, on day 7, activity post-LAVH (7.8) was significantly greater than after TAH (5.8), and, by week 3, LAVH (9.6) continued to allow significantly more activity than TAH (7.9). Patients undergoing LAVH remained in the hospital for 2.5 days, costing $12,814; patients undergoing TAH remained in the hospital for 4.5 days, costing $10,511. Therefore, patients undergoing LAVH apparently have shorter hospitalization and more rapid recuperation and return to normal activities, but they spend longer time in the operating room. Patients undergoing TAH have the prime advantage of shorter operation time. Although the hospital costs for LAVH are significantly greater than for TAH, patients who undergo LAVH usually return to work earlier and thus require less time off work. This means equally important savings in disability insurance for patients undergoing LAVH (Carter, 1994). In a study provided by Lipscomb (1997), patients undergoing LAVH were compared to patients undergoing vaginal hysterectomy. These patients were randomly assigned to these 2 categories, and their primary and secondary symptoms were fibroid tumors and pelvic pain, respectively. The surgery time for the LAVH group (120.1 ± 28.5 min) was almost twice that for the vaginal hysterectomy group (64.7 ± 27 min). The amount of blood lost in the LAVH group (203.8 ± 130.5 mL) was significantly less than the blood lost in the vaginal hysterectomy group (376.1 ± 261.5 mL). The procedures were performed on an outpatient basis, with the cost for the LAVH group ($7905 ± 501) being significantly greater than the vaginal hysterectomy group ($4891 ± 355). The postoperative pain in the 2 groups was the same, except for postoperative day 2, on which patients undergoing LAVH required significantly more pain medication than patients undergoing vaginal hysterectomy. Based on these results, LAVH apparently may not be the first choice in patients who are good candidates for vaginal hysterectomy (Lipscomb, 1997). The severity of the pathological disorder must be the key standard in selecting the type of hysterectomy, in order to maintain optimum surgical practice. In studies performed in the United States, France, and the United Kingdom in which strict guidelines based on the severity of the pathological disorder have been implemented, most patients underwent successful vaginal hysterectomy without abdominal or laparoscopic assistance (Kovac, SR 1998). In fact, after reviewing over 80 reports involving approximately 7000 patients, physician-reviewers who supported the use of systemic guidelines for selecting the appropriate hysterectomy route suggested that vaginal hysterectomy should be selected in 80% of cases because the vaginal route is contraindicated in only 10-20% of cases, eg, uterine size greater than 280 g, (Kovac SR, 1997). However, these findings should not lead physicians to disregard the use of LAVH because it still may be useful in certain cases, especially in cases with pelvic adhesions from prior surgery and infections. In order to conserve health care dollars, these reports suggest that laparoscopic techniques should not be implemented in more than 20% of scheduled hysterectomies (Kovac, 1998). In a study performed by Makinen et al (2001) in Finland during 1996, a total of 10,110 hysterectomies, consisting of 5875 abdominal, 1801 vaginal, and 2434 laparoscopic operations showed a rate of overall complications of 17.2%, 23.3%, and 19%, respectively. The most frequent complications were infections, with occurrences of 10.5%, 13%, and 9% for abdominal, vaginal, and laparoscopic operations, respectively. Injuries to the ureter were most common in the laparoscopic group (with a relative risk of 7.2) compared to the abdominal group, while bowel injuries were most frequent in the vaginal group (with a relative risk of 2.5) compared to the abdominal group. Severe hemorrhagic events occurred with frequencies of 2.1%, 3.1%, and 2.7% in the abdominal, vaginal, and laparoscopic group, respectively. From these results, the significance of a surgeon's expertise in reducing severe complications, especially in LAVH and vaginal hysterectomy, is apparent (Makinen, 2001). Follow-upAfter the surgery, it takes 4-6 weeks to recover. Recovery is earlier in cases of vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy. No lifting anything heavy for 6 weeks after the surgery. In case of oophorectomy in premenopausal women, patients experience menopausal symptoms like hot flashes, vaginal dryness, and mood disturbances. Return to normal sexual activities is expected after 6 weeks of surgery. For excellent patient education resources, visit eMedicine's Cancer and Tumors Center and Women's Health Center. Also, see eMedicine's patient education articles Cervical Cancer, Female Sexual Problems, and Pain During Intercourse. COMPLICATIONSSection 8 of 10
Possible complications of hysterectomy include surgical wound infection; excessive bleeding; injury to the bowel, bladder, ureter, or major blood vessel; urinary tract infection, postoperative thromboembolism, atelectasis, early onset of menopause, and loss of ovarian function. FUTURE AND CONTROVERSIESSection 9 of 10
Although hysterectomy is often the definitive treatment for many pelvic pathologies, nonsurgical alternatives always should be attempted in elective cases. Hormonal therapy, gonadotropin-releasing hormone antagonists, progesterone-containing intrauterine device, endometrial ablation, cryotherapy, and uterine artery embolization have been used with success. As more pharmacologic and invasive radiologic interventions become available, the number of hysterectomies performed not only in the United States but also abroad will continue to decrease. Not only will surgical techniques continue to be updated and improved, but preoperative and postoperative interventions, such as the use of epoetin alfa (Procrit), will improve morbidity, mortality, and quality of life when this surgical procedure is performed. Because the uterus is associated with femininity, some women experience a sense of loss after a hysterectomy. However, some women find a hysterectomy to enhance their quality of life because it provides relief of symptoms and definite contraception. REFERENCESSection 10 of 10
Article Last Updated: Aug 22, 2006 |
