Hysterectomy: Which route for which patient?
The vaginal route—with or without laparoscopic assistance—is often preferable to laparotomy, but much less common.
IN THIS ARTICLE
- Editorial We are at the tipping point
OUR EXPERT PANELISTS
- Moderator Mickey Karram, MD, Director of Urogynecology, Good Samaritan Hospital, Cincinnati, and Professor of Obstetrics and Gynecology, University of Cincinnati, Ohio.
- Tommaso Falcone, MD, Professor and Chairman, Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio.
- Thomas Herzog, MD, Director, Division of Gynecologic Oncology, Physicians and Surgeons Alumni Professor, Columbia University Medical Center, New York City.
- Barbara S. Levy, MD, Medical Director, Women’s Health Center, Franciscan Health System, Federal Way, Wash. Dr. Levy serves on the OBG MANAGEMENT Board of Editors.
The vast majority of hysterectomies are for benign conditions—for which minimally invasive approaches would seem appropriate—yet the ratio of abdominal-to-vaginal hysterectomy is 3 to 1 or higher.1,2 Approximately 800,000 US women undergo hysterectomy each year.
Why the continued reliance on the abdominal approach despite convincing evidence that vaginal and laparoscopicassisted vaginal hysterectomy (LAVH) offer faster recovery, better cosmesis, and, in many cases, a shorter operation with fewer complications?
OBG Management convened a panel of experts in different aspects of gynecologic surgery to explore this issue. They discuss the reasons most physicians prefer the abdominal approach, how residency programs affect the choice of hysterectomy route, indications for LAVH and supracervical hysterectomy, the issue of ovarian conservation, and management of uterine fibroids.
Why the abdominal route remains the old standby
Physicians use the procedure they are most comfortable with, and residents lack sufficient hands-on experience with laparoscopic and vaginal surgery. Medicolegal risk and reimbursement also have an impact.
KARRAM: Hysterectomy is one of the most widely performed surgeries in the United States, but approximately 60% to 80% of these surgeries still involve the abdominal route.2 Why do you think that is?
FALCONE: Most physicians practice in the manner they were trained, and most residency programs train residents to perform abdominal hysterectomy.
LEVY: I agree. Residents in obstetrics and gynecology have a limited time frame in which to learn and become facile with surgical gynecology. The requirements for primary care training and continuity clinics leave little time for the resident to become comfortable with endoscopic and vaginal surgery. However, they do get substantial exposure to abdominal surgery, both in obstetrics (with cesarean sections constituting 27.5% of all deliveries in the United States3) and gynecologic oncology rotations.
Furthermore, the volume of benign gynecologic surgery is low and the technical skills required for laparoscopic and vaginal surgery are more challenging than “slash and gash” abdominal surgery, so residents don’t get enough exposure to develop a comfort level with these procedures.
HERZOG: This trend is likely to change in the future because recent and current trainees have much more exposure to the laparoscopic approach than in the past, and the equipment has continued to improve. However, I have serious doubts about whether adequate amounts of vaginal surgery are performed in training programs to educate the next generation of vaginal surgeons.
LEVY: Another factor is the type of practice physicians enter after training. Most join practices in which the bulk of their income for many years derives from obstetrics. Without a mentor in the practice who is skilled at minimally invasive surgery, most of these young physicians appropriately resort to the hysterectomy approach for which they have the most comfort and skill: the abdominal route.
HERZOG: Secondary barriers to nonabdominal procedures are lower reimbursement and heightened medicolegal risk, since time and complications are greater for laparoscopic surgery and, to a lesser degree, vaginal procedures. Surgeons are not adequately compensated for either the increased time or risk.
Patients also tend to have higher expectations when the planned approach is minimally invasive. When conversion to laparotomy is necessary, the patient and her family may have trouble understanding why.
KARRAM: I agree that there is a serious lack of training in simple and complicated vaginal hysterectomy. Many inaccurate perceptions have been handed down over the years about its absolute and relative contraindications, such as the belief that any history of pelvic infection, endometriosis, or cesarean section is a contraindication for the vaginal approach.
When is laparoscopic assistance appropriate?
At a fundamental level, its value lies in converting abdominal hysterectomy intovaginal hysterectomy.
KARRAM: In my experience, LAVH is appropriate in the presence of benign adnexal pathology: The adnexa can be evaluated and detached laparoscopically followed by vaginal hysterectomy and vaginal removal of the adnexa. It also is appropriate in any situation that involves excessive pelvic adhesions. The uterus can be mobilized laparoscopically, followed by removal through the vagina.
FALCONE: Any patient who is not a candidate for vaginal hysterectomy should be considered for laparoscopic assistance. The general rationale for the surgery is to convert an abdominal hysterectomy into a vaginal one, so the surgeon should start laparoscopically and then switch to the vaginal approach as soon as possible. Of course, it is impossible to proceed vaginally in some cases. When it is, the entire case can be performed laparoscopically.
LEVY: In my hands, patients with an unidentified adnexal mass who also need or request hysterectomy are appropriate candidates for laparoscopic abdominal exploration followed by vaginal hysterectomy if appropriate. Women with a very contracted pelvis, which precludes transvaginal access to the uterine vasculature, may also be candidates for the laparoscopic approach. However, as surgeons become more skilled at vaginal surgery and learn to use newer instrumentation, the need for laparoscopy to access a tight pelvis will diminish.
Using a laparoscopic approach for patients with fibroids wedged into the pelvis carries serious risk to the pelvic sidewall. It is very difficult to access the sidewall safely laparoscopically in the presence of a large lower segment or cervical myomas.
HERZOG: When LAVH was introduced, many clinicians challenged the utility of combined laparoscopic and vaginal surgery, with some referring to this surgical exercise as a procedure looking for an indication. However, as operative laparoscopy has gained acceptance, some benefits of LAVH have become apparent. The greatest advantage is the potential to convert a procedure that would have been performed abdominally into a vaginal hysterectomy.
The most commonly cited indications for LAVH are to lyse adhesions secondary to prior abdominopelvic surgery, substantial endometriosis, or a pelvic mass.
The need to remove the ovaries does not mean laparoscopic assistance is imperative.
HERZOG: Simple removal of the ovaries can often be performed using the vaginal route, and is not in itself an indication for LAVH.
LEVY: I agree. The ovaries can usually be accessed transvaginally, especially with good fiberoptic lighting and vessel-sealing technology.
FALCONE: Several studies, most notably the one by Ballard and Walters,4 demonstrate that oophorectomy can be carried out vaginally in most cases. In their study, they did not use special instruments.
HERZOG: But LAVH is indicated to facilitate complete removal of the ovaries in riskreduction surgery for documented or suspected BrCa 1 or 2 mutations. The entire ovary and as much of the tube as possible must be removed in these women. Thus, if the patient has other indications for hysterectomy, LAVH may be the preferred route to assure that the blood supply is taken proximally enough to remove absolutely all ovarian tissue. Simply clamping directly along the side of the ovary is not an adequate removal technique for these patients, since an ovarian remnant may become a fatal oversight.
LEVY: Yes, laparoscopy is indicated for riskreducing salpingo-oophorectomy in order to adequately assess the entire peritoneal cavity. Up to 2% of these patients will have occult invasive ovarian or peritoneal carcinoma at the time of their prophylactic surgery, so full surgical abdominal exploration is mandatory and can be nicely accomplished via laparoscopy.5
How endometriosis history affects choice of route
In some women, laparoscopic surgery is preferred over the vaginal route.
FALCONE: Hysterectomy with or without salpingo-oophorectomy can be considered in women whose endometriosis fails to respond to conservative management and who do not desire fertility. Most studies have shown substantial pain relief with definitive surgery.6,7 Although ovarian conservation may be advisable in younger women, in some women it increases the probability of recurrent pain and the need for reoperation. The main concern is whether the endometriosis is completely removed during hysterectomy.
A history of cul-de-sac obliteration or extensive pelvic adhesions from endometriosis is an indication for laparoscopic hysterectomy rather than vaginal hysterectomy. Women with less severe disease will benefit from a diagnostic laparoscopy prior to a vaginal hysterectomy to evaluate the pelvis and excise any endometriosis.
There is no evidence of any benefit except in selected cases of heavy bleeding, postpartum hemorrhage, advanced endometriosis, or ovarian cancer surgery.
KARRAM: What about supracervical hysterectomy? The only time I have performed one was at the time of a cesareanhysterectomy because blood loss was significant and dissection of the cervix could have led to more morbidity. What are the indications for this procedure?
HERZOG: It is unclear whether there are any definitive indications for supracervical hysterectomy. A number of benefits have been proposed, such as better support and improved sexual function. Some of the perceived benefits have been supported by nonrandomized trials, but critical analysis of the randomized data has failed to support most of these contentions.8,9 However, the procedure can be a valuable intervention to decrease critical blood loss intraoperatively, as you point out, or to simplify complicated pelvic surgery in selected cases, such as postpartum hemorrhage, advanced endometriosis, ovarian cancer debulking (when the cervix is not involved), or significant bleeding in patients who object to transfusion on ethical or religious grounds.
FALCONE: There are clear contraindications to supracervical hysterectomy, namely the presence of a malignant or premalignant condition of the uterine corpus or cervix, but no indications, except perhaps for an unstable patient undergoing hysterectomy in whom you want to finish quickly. None of the randomized clinical trials have shown supracervical hysterectomy to be superior to total hysterectomy. The randomized trials involved the abdominal route; the time to complete a laparoscopic supracervical hysterectomy is less than for a laparoscopic total hysterectomy.
Nevertheless, many patients ask for the procedure. After I present the risks and benefits, I leave the choice up to them. Of course, it is important to explain that total hysterectomy implies removal of the cervix and not the ovaries.
LEVY: In rare cases of immunocompromised patients or women with widely disseminated intraperitoneal carcinoma, one could make an argument for avoiding entry into the vagina to reduce infectious risk, speed healing, or avoid tumor seeding. Otherwise, there is absolutely no evidence to support an indication for supracervical hysterectomy.
Does leaving the cervix affect long-term function?
The residual cervix can become the site of later neoplasia or disease.
HERZOG: Supracervical hysterectomy can be associated with several problems with longterm implications. One is the potential for cervical intraepithelial neoplasia. Another concern relates to bleeding from a portion of active endometrium at the top of the endocervical canal. Rarer problems include the development of endometriosis or invasive cancer in the residual cervix. These potential drawbacks need to be strongly considered and included in patient counseling.
KARRAM: One study followed 67 patients for 66 months after supracervical hysterectomy; trachelectomy was ultimately required in 22.8% of patients.10
The $64,0000 question: Remove the ovaries?
Overall, the decision should be made case by case.
KARRAM: Should routine oophorectomy be performed at the time of hysterectomy in postmenopausal women to decrease the potential for ovarian cancer later in life?
HERZOG: This is a very important question. Conventional thinking used to be that, for women over the age of 45, and certainly for women older than 50, ovarian removal should be strongly considered to reduce the risk of cancer of the ovary or fallopian tubes at a later date. Studies focusing on the number of ovarian cancer cases possibly prevented with routine oophorectomy at the time of hysterectomy reinforced this concept. One single-institution study showed that more than 60 cases of ovarian cancer would have been prevented over a 14-year period if ovaries were routinely removed in women older than 40 undergoing hysterectomy. By extrapolation, that would result in more than 1,000 cases prevented annually in the United States.11