Overview of Current Trends in Hysterectomy

Santiago Domingo; Antonio Pellicer

Disclosures

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

In This Article

Expert Commentary

One of the greatest achievements of the hysterectomy policy is the reduction in the rate of hysterectomy indication. The LNG-IUD, among the most important advances in menorrhagia treatment, and other conservative approaches are to be thanked for this progress. This situation will probably continue, although we suspect that these methods are not as widespread in medical practice as they should be. One of the adversities that clinicians must struggle with is a lack of knowledge regarding the benefits offered to patients by alternative therapies. Why does clinical decision making not evolve with new advances? Currently, many women enter the operating theater without having been submitted to more conservative approaches or at least having discussed alternatives with medical staff. Another regrettable circumstance is the economic impact for a surgeon of avoiding surgery, which can lead to misguided priorities in the decision of whether or not to perform a hysterectomy.

When a hysterectomy is decided upon, there are many circumstances that should be taken into account. Patient opinion and surgeon integrity are transcendental. Many women are not even informed of which method of hysterectomy they are about to undergo when admitted to hospital. Patients should be informed of the characteristics of the different routes and their benefits and disadvantages. Clinicians should ask themselves if the skills and technology available in a medical center are made clear when counseling patients. Worryingly, some decisions are made during surgery without the scientific evidence to back them up, such as the performing of a 'free' bilateral adnexectomy. This subject deserves extensive discussion elsewhere, as it is not within the scope of the present review. We should be conscious of the great negative impact that hysterectomy can have on QoL. Moreover, if the ovaries are preserved when a hysterectomy is performed between the ages of 50 and 54 years, there is a 10% increase in the probability of surviving to the age of 80 years. The 0.5% survival advantage estimated as a result of preventing ovarian cancer is not a convincing enough reason to choose an abdominal approach. Patients put their trust in medical personnel, and we should make decisions based purely on the scientific evidence available. For example, an argument for VH is the lack of a need to perform a bilateral salpingo-oophorectomy, which is known to be more complicated.

Apart from openly discussing the three methods of hysterectomy and their respective indications, the surgeon's skill with respect to each of the three routes must be a factor. If we ask whether surgeons are frank about their competency in each route, the answer is probably no. Some surgeons remain reluctant to change their practice patterns, tending to select the abdominal route without considering the feasibility of the vaginal route. However, if we are to be more rigorous in our clinical decision making, some changes must occur within gynecological programs. It seems that the objectives of teaching of appropriate hysterectomy routes have become confused. The aim of all hysterectomy guidelines is to avoid a laparotomy whenever possible, but a look at the literature reveals the opposite, as there is a general vaginal school versus laparoscopic school tendency. Current gynecological practice should focus on converting more AHs into LHs and VHs. Given that the advantages of LH are quite similar to those of VH, we believe that the vaginal route is the best approach, although there is no doubt that this choice depends on surgical skills, patient characteristics and available operating facilities. LH may be used to complement a vaginal approach when difficulties and absolute/relative contraindications are present, or if other pelvic/abdominal procedures are to be performed, as it is an appropriate treatment for endometriosis or for staging in oncology.

What direction must we take in the future? First, we must improve the training of resident doctors in vaginal surgery. Vaginal anatomy is often taught inadequately. The ability to perform some of the technical aspects of VH, such as opening the anterior and posterior peritoneum, is often more of a challenge than a 'usual practice'. These steps should be as routine as opening abdomen layers for a gynecologial surgeon. Clinicans need to lose their fear of uterus morcellation. This procedure is uncomplicated in most cases as, fortunately, it is not commonly performed in uteri of sizes larger than those at 12 weeks of pregnancy. Once uterine vessels are clamped, one to three vaginal myomectomies are enough to remove the uterus from the pelvis. Although many surgeons and residents are not accustomed to this procedure, morcellation is a safe step in vaginal delivery. Second, gynecological centers need to update their clinical guidelines for the treatment of pathologies of the uterus. A decision-making algorithm offers gynecologists a more structured surgical approach, avoiding personal practice styles that may favor a single route or method. Third, all medical decisions should be based on available scientific evidence. A continuous updating of knowledge should form an integral part of our professional life, as what is current in the present quickly becomes outdated in the future. We cannot rely soley on what we learnt in our residence programs, but must constantly move forward by updating our training and allowing our surgical techniques and their indications to evolve.

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