Gynecology Book

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HysterectomyAka: Transabdominal Hysterectomy, Laparoscopic Assisted Vaginal Hysterectomy, Vaginal Hysterectomy

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  1. Epidemiology: United States
    1. Annual Incidence: 600,000
    2. Surgically absent uterus in 40% over age 60 years
    3. Most hysterectomies are for benign disease
  2. Indications
    1. Most common indications
      1. Uterine Leiomyoma (Uterine Fibroids) - most common
      2. Abnormal Uterine Bleeding
      3. Endometriosis
      4. Uterine Prolapse
    2. Cancerous and precancerous indications
      1. Endometrial Cancer (10%)
      2. Endometrial hyperplasia (5%)
    3. Other indications
      1. Persistent Cervical Dysplasia
      2. Adenomyosis
      3. Peripartum bleeding
  3. Procedures
    1. Transabdominal Hysterectomy
      1. Lowest quality of life scores
      2. Highest hospitalization and postoperative costs
      3. Twice the risk of postoperative fever
      4. Significantly increased blood loss
      5. Prophylactic antibiotics are recommended
      6. Peipert (2004) Obstet Gynecol 103:86
    2. Laparoscopic Assisted Vaginal Hysterectomy
      1. Same life quality as Vaginal Hysterectomy at 28 days
    3. Vaginal Hysterectomy
      1. Fastest return to normal activities
      2. Highest quality of life scores
      3. Lowest hospitalization and postoperative costs
  4. Adverse Effects (serious complication rate: 10%)
    1. Mortality: 6 per 10,000 operations
    2. Urinary Incontinence (increases risk by 40-80%)
    3. Does not adversely effect sexual function
      1. Sexual well-being improves after Hysterectomy
      2. Roovers (2003) BMJ 327:774
  5. Precautions: Prophylactic Oophorectomy at time of Hysterectomy
    1. Benefits
      1. Ovarian Cancer significantly reduced
        1. Note Hysterectomy alone also reduces risk by 35%
      2. Breast Cancer risk is reduced by 50%
    2. Risks (if oophorectomy performed before age 45)
      1. Overall mortality increases
      2. Osteoporosis risk increases
      3. Cardiovascular disease risk increases
      4. Dementia risk increases
    3. References
      1. Parker (2005) Obstet Gynecol 106:219
      2. Rocca (2006) Lancet Oncol 7:821
      3. Rocca (2007) Neurology 69:1074
  6. References
    1. Ryan (1999) Kistner's Gynecology, Mosby, p. 137-9
    2. Brown (2000) Lancet 356:535
    3. van den Eeden (1998) Am J Obstet Gynecol 178:91

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