Total versus subtotal hysterectomy for benign gynaecological conditions

May 23 2006

Women who undergo a total hysterectomy, in which both the uterus and the cervix are removed, are no more likely to experience sexual difficulties or urinary or bowel problems after surgery than women who have only their uterus removed, a new review has found.

This finding contradicts perceptions among some women and physicians that retaining the cervix is preferable or even necessary to pelvic function.

Total hysterectomy is a slightly more complex and lengthy operation, but the likelihood of ongoing menstrual bleeding after surgery is increased with subtotal hysterectomy.

"Women considering surgery will have to balance the supposed advantages of a less complicated surgery with a risk of cyclical bleeding after subtotal hysterectomy," said lead author Anne Lethaby of the University of Auckland in New Zealand. "The review did not find any other differences."

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

The rationale for the review, according to the authors, was to compare the safety and effectiveness of subtotal and total hysterectomy and to evaluate the perception that total hysterectomy could increase the risk of urinary incontinence, bowel problems and reduced sexual pleasure.

The reviewers identified three randomized controlled trials enrolling a total of 733 women that compared subtotal and total hysterectomy for noncancerous conditions. The most common reasons for hysterectomy in these trials were fibroids and heavy menstrual bleeding.

There was no evidence in these trials that total hysterectomy increased the risk of urinary or bowel problems. In the two years following surgery, women receiving a total hysterectomy were no more likely to suffer from urinary incontinence, increased urinary frequency or constipation than women who underwent subtotal hysterectomy.

They also found no evidence from these trials that removal of the cervix impaired sexual function. Satisfaction with sex, prevalence of painful intercourse and rates of sexual problems in the year or two following surgery did not differ significantly according to the type of hysterectomy.

"Early studies taught that subtotal hysterectomy was better than total hysterectomy in terms of sexual function, urinary function, and GI function, but these studies were not well done," said Howard Sharp, M.D., of the University of Utah School of Medicine. "Now that we've had a few studies that have been done with a much higher degree of scientific rigor, they're showing us that there's really no difference in terms of these outcomes."

The reviewers did find that women having total hysterectomy had a greater risk of fever during surgery. Operating time was about 11 minutes shorter for subtotal hysterectomy in the two trials that measured this, and women who underwent subtotal hysterectomy in these studies also lost less blood, on average, than women having total hysterectomy. However, there was no significant difference in the need for blood transfusions according to type of surgery.

"An 11-minute difference in the operating room is statistically significant, but I think it's clinically irrelevant," said Sharp. "And while we would all like to hang on to every drop of blood we can get, what really matters to me is whether I have to transfuse a patient."

Another potential disadvantage of total hysterectomy, an increased risk of vaginal vault prolapse, was not confirmed in the review. The authors noted that to assess this risk properly, longer follow-up of trials would be needed.

One significant difference of possible relevance to some women was the greater likelihood of ongoing cyclical vaginal bleeding with subtotal hysterectomy. Almost 12 percent of women having subtotal hysterectomy were experiencing ongoing bleeding one year after surgery was completed, compared to fewer than 1 percent of women having total hysterectomy.

"I've had patients who have had cyclical bleeding after subtotal hysterectomy, but most patients state that it's just a nuisance issue," said Sharp. "However, if definitive treatment is what they want, I make sure that I counsel them about the potential for post-hysterectomy spotting with subtotal hysterectomy."

According to Lethaby, the review cannot be considered definitive, due to the small number of studies that have compared total and subtotal hysterectomy and the fact that fewer than a thousand women were enrolled.

"While the risks and benefits are clear in the review, more research is required before we can be confident of the findings," she said.