Hysterectomy for Undergraduates Max Brinsmead MB BS Ph

Hysterectomy for Undergraduates Max Brinsmead MB BS Ph. D May 2015

Indications for Hysterectomy n n n n Fibroids Menstrual dysfunction Prolapse Endometriosis Adenomyosis Pelvic Inflammatory Disease Cancer Cervix n Uterus n Ovaries n

Alternatives to Hysterectomy n Medical treatment of bleeding problems or endometriosis n Endometrial resection for menorrhagia n Myomectomy and uterine artery embolisation for fibroids n Radiotherapy for Ca cervix n A number of RCT’s and systematic analyses compare these alternatives n So clinician-guided and informed patient choice is an important component of best practice

Types of Hysterectomy n Subtotal Hysterectomy n Uterine body only n Total Hysterectomy n Uterine body and cervix (not ovaries!) n Hysterectomy with BSO n Uterus with bilateral salpingo oophorectomy n Radical (or Wertheim) Hysterectomy n Total hysterectomy with pelvic lymph nodes, paracervical tissue and upper 1/3 vagina

Routes for Hysterectomy n Abdominal Hysterectomy (AH) n n Total Subtotal n Vaginal Hysterectomy (VH) n Laparoscopic Hysterectomy n Laparoscopically-assisted vaginal (LAVH) n Totally laparoscopic hysterectomy

Which Route is Best? n Abdominal Hysterectomy n n n Results in greatest mean blood loss Has the highest incidence of febrile morbidity And abdominal wound infection (obviously) Longest hospitalisation And slowest to recover n Vaginal Hysterectomy n Is the preferred route when technically possible n Laparoscopic Hysterectomy n n n Requires training and equipment Longest operating time But shortest hospitalisation and recovery But has the greatest overall risk of complications There is debate about its cost effectiveness

Complications of Hysterectomy n Infection n n n Abdominal incision Vaginal vault and pelvic Infected haematoma Blood loss and anaemia Bladder dysfunction or Cystitis Bowel dysfunction Damage to: n n n Bladder Bowel Ureters n Depression or Sexual Dysfunction n Longer Term n n n Prolapse Wound pain Earlier menopause

“Ball-Park” Risks with Hysterectomy n 30 – 40% minor complication rate n 1: 10 risk of “unpleasant” complication n 1: 20 risk of transfusion n 1: 50 risk of serious complication n But <1: 100 with ongoing problems n 1 -3: 1000 risk of death n Complications are some 1. 5 -fold more common if there are fibroids

Removal of the Cervix n n n n n Is only an option during abdominal hysterectomy Technically more difficult So operative time and blood loss is increased But a good option when things are going badly Some evidence for more bladder problems when it is left (about 2 -fold) Sometimes “mini periods” if it is left (about 7%) 2% risk of cervical prolapse when it is left Main argument for removal is risk of CIN and Ca But the cervix does not have any sexual function n Confirmed by RCTs

Bilateral Oophorectomy during Hysterectomy? n 1: 80 lifetime risk of ovarian cancer n Bilateral oophorectomy reduces the risk of breast Ca n Is more important for the woman at risk n e. g. those with BRAC 1&2 mutations n But up to 1: 10 pre menopausal women undergoing n n hysterectomy return for surgery to remaining ovaries n This can be technically difficult And PMT-symptoms can be a major problem for a few women Oophorectomy may be important if there is peritoneal endometriosis Adds little to operative time and risk during AH But may be quite difficult in up to 30% during VH

Bilateral Oophorectomy during Hysterectomy 2? n The major problem is that of premature menopause n And symptoms from a surgical menopause seem to be more severe n Many women feel very strongly about ovarian removal n And there is a dearth of information about any endocrine role for postmenopausal ovaries n n n They continue to produce androgens Which may have a role in well-being and libido And are converted to oestrone by fat cells n Age is one factor that has a major role in deciding about bilateral oophorectomy n n Below the age of 45 – aim for preservation Above the age of 65 – balance tips in favour of removal

After Hysterectomy n Most women don’t need Pap smears n Except those who had previous CIN >2 , Ca Cervix or Ca corpus uterus n Oestrogen only HRT (ERT) is an option n Except when BSO was performed for oestrogen responsive cancer or severe endometriosis Symptoms control in these patients can be a real problem Current research suggests that ERT has many benefits and few risks

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