Hysterectomy
Hysterectomy dates back to ancient times and the first vaginal hysterectomy is thought to have been performed by Soranus of Ephesus, 120 years AD.[5] Today, the rate of hysterectomy differs between countries, but also within countries, depending on differences in morbidity, health economy, therapeutic traditions and attitudes.[6,7] In the USA, approximately 600,000 operations are carried out annually,[1] and almost one-third of women have had a hysterectomy by the age of 60 years. In the UK, the corresponding figure is one in five women.[8] The rate of hysterectomy has decreased slightly in several countries during recent years,[9,10] which is often attributed to the advent and increased use of alternative, less invasive treatment options.[11,12] Lower educational status and income has, according to several studies, been associated with a higher incidence of hysterectomy,[13,14] although other studies contradict this.[15]
There are several modes of hysterectomy: total abdominal hysterectomy, where the entire uterus including the cervix is removed; subtotal abdominal hysterectomy, where only the uterus is removed; and radical hysterectomy performed for malignancies. Hysterectomy, either total or subtotal, may be performed by different techniques, including the vaginal route, laparotomy or laparoscopy.
Abdominal hysterectomy has traditionally been used as the surgical approach for gynecological malignancies or when other pelvic pathology is present, such as endometriosis, abdominal adhesions and when the uterus is enlarged. It also remains the 'fallback option' if the uterus cannot be removed by another approach.[2,16]
Vaginal hysterectomy was originally only used for uterine prolapse, or when concomitant vaginal prolapse surgery was indicated, but it has become increasingly used for other indications such as dysfunctional bleedings when the uterus is of a fairly normal size. Compared with abdominal hysterectomy, vaginal hysterectomy is less invasive and has advantages, such as a quicker return to normal activities, less postoperative pain and fewer perioperative infections. Thus, most systematic reviews agree that vaginal hysterectomy should be performed in preference to abdominal hysterectomy when possible.[3]
Hysterectomy may also be performed by laparoscopy, either by laparoscopic-assisted vaginal hysterectomy, where only a part of the hysterectomy is performed by laparoscopy, by laparoscopic hysterectomy (LH), where most of the surgery is performed by laparoscopy or by total LH, where the entire operation is performed by laparoscopy.[3] Robotic surgery is also becoming more frequently used, but most commonly for radical hysterectomy.[17] Compared with abdominal hysterectomy, LH is associated with a higher rate of major complications and takes longer to perform, but is associated with less postoperative pain and a shorter hospital stay.[16] In patients where vaginal hysterectomy is not possible, some suggest that LH should be performed in preference to abdominal hysterectomy.[3]
Approximately 90% of hysterectomies are performed on benign indications to improve quality of life,[18] and the most common indication for surgery is uterine fibroids.[2,9,10,19] Hysterectomy on benign indications is generally regarded as a safe procedure in developed countries with a low perioperative morbidity rate and relatively few short-term complications.[20] The mortality rate is estimated to be 0.4% and the rate of severe complications approximately 3%.[21] The rate of perioperative complications is reported to be 20% or higher, depending on definition, but also related to mode of hysterectomy.[3,22] The most common perioperative complications of hysterectomy are infections or hematomas (wound infection, vaginal cuff infection or bleeding and urinary tract infection). The short-term effects of hysterectomy on quality of life are satisfactory according to most studies and the procedure has been the mainstay of gynecological surgery for decades.[23] The long-term effects of hysterectomy are, however, not as well investigated as the perioperative morbidity and short-term consequences. For the purpose of this review, the long-term effects of hysterectomy are limited to hysterectomy on benign indications.
Aging Health. 2013;9(2):179-187. © 2013 Future Medicine Ltd.
