B3. Indications and methods of hysterectomy

Last updated on June 8, 2021 at 19:26

Definition and indications

Hysterectomy is the surgical removal of the uterus, sometimes with other surrounding structures as well. It is the most common gynaecological surgery.

The main indications for hysterectomy are gynaecological cancer and precancerous lesions (vaginal, cervical, endometrial, ovarian, gestational), but hysterectomy is also an option in several conditions when they are refractory to medical treatment:

  • Pelvic organ prolapse
  • Adenomyosis
  • Endometriosis
  • Pelvic inflammatory disease
  • Uterine leiomyoma

Vaginal, abdominal, and laparoscopic hysterectomy

The hysterectomy may be performed by the vaginal, abdominal, or laparoscopic route.

In general, vaginal hysterectomy is preferred because of lower cost, lower complication rates, and shorter hospital stay. Vaginal hysterectomy can be problematic in nulliparous and obese women. The uterus is removed through an incision in the vagina.

Laparoscopic hysterectomy is the second choice. It may allow for same-day discharge if the patient has no comorbidities that require inpatient care and there are no perioperative complications.

Sometimes, these routes may be combined, for example as in laparoscopically assisted vaginal hysterectomy (LAVH).

Supracervical, total, and radical hysterectomy

Supracervical or subtotal hysterectomy means the removal of the uterus only, not including the cervix and vagina. There are few or no advantages of this compared to total hysterectomy.

Total or simple hysterectomy means the removal of the uterus and cervix, not including the vagina.

Radical hysterectomy (Wertheim operation) means the en bloc removal of the uterus, fallopian tubes, ovaries, cervix, upper 1/3 of the vagina, and parametrium. The pelvic and sometimes para-aortic lymph nodes are also removed. It is used in the case of malignancy.

Oophorectomy or salpingo-oophorectomy

Bilateral oophorectomy and salpingo-oophorectomy refer to the removal of the ovaries or the tubes and ovaries, respectively. These procedures may be performed simultaneously as the hysterectomy if there are indications for it, like:

  • Presence of or high risk for ovarian cancer
  • Endometriosis

Complications of hysterectomy

  • Major haemorrhage
  • Thromboembolism
  • Urinary tract injury – ureteral or bladder injury
  • Bowel injury
  • Pelvic organ prolapse

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B4. Functional diagnostics of the ovarian capacity, cycle diagnostic

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