Overview of Current Trends in Hysterectomy

Santiago Domingo; Antonio Pellicer

Disclosures

Expert Rev of Obstet Gynecol. 2009;4(6):673-685. 

In This Article

Five-year View

Hysterectomy policy requires a change. It is essential to explore all the medical tools available to treat uterine disease in order to offer our patients more conservative treatments rather than surgery. Global surveillance of women's health is improving, and reaching the eighth decade is normal in developed countries. Hysterectomy rates are expected to decrease as, although the genital prolapse rate is sure to rise, menorrhagia, the most frequent indication for a hysterectomy, is increasingly treated with more effective alternative methods. The scenario in the developing world is different, with menorrhagia often posing a life-threating problem, making hysterectomy the first and sole treatment for the related anemia.

Randomized studies of the long-term outcomes of new alternatives compared with those of hystererectomy need to be updated, focusing on cost–effectiveness, QoL and complications. We believe that the LNG-IUD will have an important impact on the treatment of menorrhagia in the future, as its clinical application increases yearly. Moreover, the LNG-IUD may play an enormous role in preventing endometrial pathology, owing to its strong antiproliferative effect. Studies are required to evaluate its preventive efficacy in endometrial hyperplasia. Many patients with risk factors (e.g., obesity or polycystic ovarian syndrome) are sure to benefit from advances that prevent pathologies and consequential hysterectomies. Newly available drugs, such as the progestin receptor modulators, are promising alternatives. In addition, new second-generation ablation techniques will no doubt improve their results with time and become serious rivals of hysterectomy. Why is ablation not applied in clinical practice as frequently as it should be? The fact that this approach is unsuccessful among almost a quarter of patients 5 years after the procedure is discouraging. Future research should focus on a definitive destruction of the basal endometrium and, if possible, a definitive sinequia of the entire endometrial cavity.

National healthcare systems should monitor hysterectomy policy, as it is one of the most prevalent surgeries among the population. How much money could be saved if standard guidelines were followed? New criteria must be considered when selecting the route of hysterectomy, and vaginal surgery programs should be promoted. There is a need for vaginal and laparoscopic surgery training programs in every country and institution. Reports continuously show that VH/AH rates can be dramatically changed without surgical complications. It is more than probable that, in a few years, such changes will be undertaken in many centers, as patients will demand a less invasive approach to treating their problems. Laparoscopic surgery is increasingly accessible to gynecologic surgeons and surgical devices, such as uterine manipulators and sealing systems, make surgery easier to perform and more reproducible. Robotic surgery shows great potential. Its short learning curve, the 3D view it affords, and the better access to the pelvis and deep pelvis that it allows (owing to the instrumental tips) convert it into an attractive alternative, although its excessive cost makes it an unfeasible option for such a prevalent form of surgery. Although all surgeons should be well trained in both vaginal and laparoscopic procedures, it is likely that controversy surrounding the two approaches will continue. We believe that, in a few short years, current AH rates will have been reduced radically so that they account for less than 10% of surgical procedures.

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