Overview of Current Trends in Hysterectomy

Santiago Domingo; Antonio Pellicer


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

In This Article

Hysterectomy Complications

The two fundamental aspects to be considered when studying hysterectomy complications are surgical and functional.

Surgical Complications

The three types of hysterectomy have been compared in terms of complications. In the most recent meta-analysis,[40] urinary tract injury was significantly higher in LH than AH (odds ratio: 2.61), while no significant differences were found in LH versus VH (odds ratio: 1) or total LH versus LAVH. No significant difference was observed between other intraoperative visceral injuries (bowel or vascular) as a result of the surgical approaches.

The abdominal approach has constantly been related to a higher incidence of febrile episodes and wound infections. Although no differences have been reported with respect to blood transfusion, LH has been associated with a smaller drop in hemoglobin and blood loss. As discussed previously, AH involves the longest hospital stay of all the hysterectomy routes, while VH and LH require similar inpatient convalescence. When analyzing operation time, the laparoscopic approach is a more time-consuming technique than AH (mean difference: 18 min) and VH (mean difference: 44 min). The operation time of LAVH was significantly shorter than that of LH (mean difference: 23 min).[40]

Impact on Pelvic Floor Dysfunction

Recent robust studies suggest that significant postoperative morbidity due to pelvic organ dysfunction is not common after total hysterectomy (TH). When performing a hysterectomy, anatomical relationships are disrupted and the local nerve supply to the pelvic organs (e.g., bladder or rectum) is damaged, the latter of which is more frequent in radical hysterectomy. Obviously, these complications can alter pelvic organ function and support. These adverse effects tend to be less serious after sub-TH (STH). In fact, sexual function improves after this intervention, which is why in the 1980s–1990s the surgical trend moved in this direction.[77,78] The Maryland Women's Health study, the largest prospective study to date, investigated the effects of hysterectomy with and without concomitant urinary incontinence repair on incontinence severity.[79] Interestingly, they found that most women with severe and moderate urinary incontinence before hysterectomy noted an improvement 1 year after surgery and further improvement at 2 years, but women with no incontinence before hysterectomy had new-onset incontinence 1 year after surgery (17%). Indeed, hysterectomy reduced previous urge-frequency symptoms, and new symptoms were observed in only 4% of cases at 1-year follow-up. In the face of these contradictory results, randomized studies comparing TH and STH have concluded that simple hysterectomy does not adversely affect urinary function and may even lead to improvement.[80,81] Furthermore, STH has been shown to not confer any benefits over TH in terms of bladder function.

There is no evidence that hysterectomy produces bowel dysfunction or exerts a negative influence on sexual function. Recently, a systematic review of sexuality after hysterectomy concluded that research in this area was largely retrospective and lacked valid outcome measures.[82] Most studies have shown either no change or an enhancement of sexuality following hysterectomy. Even when compared with more conservative management (endometrial ablation), no differences have been found.[83] Conservation of innervation when performing a STH may improve sexual intercourse, but there have been no reports of a difference in the frequency of intercourse or orgasms when TH and STH are compared. In fact, one study reported a significant increase in the frequency of intercourse and a decrease in dyspareunia following hysterectomy,[84] the latter of which has been confirmed by more recent evidence.[80] This suggests that the cervix per se does not play a major role in sexual response.

A hysterectomy is one of the most influential factors in genital prolapse. The incidence of vault prolapse following this operation is substantial, at between 0.2 and 43%.[85] It occurs more frequently when the vaginal route (10%) is preferred to the abdominal route (2%). Indeed, the former approach is frequently associated with some grade of prolapse.[86] However, an in-depth analysis reveals that VH per se is not a risk factor for vault prolapse.[87] This condition is normally due to the formation of an enterocele after a hysterectomy, which begins as a small intestine hernia that progresses to the vagina. A McCall's culdoplasty should always be performed in these circumstances, as it strengthens the DeLancey level I and avoids this physiopathological mechanism.


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