Hysterectomies

Question 1

Cochrane review 2009: surgical approach for hysterectomy for benign disease

What are the main findings/recommendations from this review?

Answer 1

Vaginal hysterectomy is preferred followed by laparoscopic hysterectomy and then abdominal hysterectomy.

VH vs AH:

• Fewer post-op fevers for VH.
• Return to normal activity shorter for VH.

LH vs AH:

• Fewer post-op fevers and wound infections for LH.
• Return to normal activity shorter for LH.
• More ureteric injuries for LH
• Longer operating time for LH.

VH vs LH:
- No advantage except longer operating time for LH.

Question 2

What are frequent risks associated with hysterectomy?

Answer 2

○ Wound infection, bruising, delayed wound healing, keloid scar formation.
○ Numbness, tingling, burning around scar (self-limiting but may take weeks to months to resolve).
○ Urinary frequency or UTI
○ Ovarian failure

Question 3

Subtotal vs total hysterectomy Cochrane review:

What were the main differences and recommendation from this review?

Answer 3

• No difference in urinary, bowel or sexual function at 2 and 9 years.
• SH had more cyclical vaginal bleeding 2 years after operation.
• SH less likely to have post-op fever and urinary retention.
• Non-significant reduction in operating time (11 mins) and amount of blood loss (57 mL)
• Recommendation: perform total hysterectomy where possible.

Question 4

Outline how you would counsel a patient undergoing hysterectomy for benign condition on how you will manage the adnexae:

Answer 4

Discuss benefits and risks of removing ovaries, particularly if <65 years old.

Discuss the risks and benefits of bilateral salpingectomy.

Consider factors such as:

• Real and perceived risk of ovarian cancer
• Indication for hysterectomy and planned surgical approach
• Personal risk factors for CHD, osteoporosis and depression
• Contraindications to HRT

Question 5

If after appropriate counselling, a woman is still worried about her risk of ovarian cancer by retaining the ovaries, should you proceed with BSO?

Answer 5

Yes.

BSO does not increase operating time or immediate surgical complications

Question 6

List the potential benefits of BSO at hysterectomy for benign disease:

Answer 6

• Reduced risk of ovarian cancer

- Reduced risk of breast cancer

Question 7

List the potential risks of BSO at hysterectomy for benign disease:

Answer 7

Increased risk of:

• Mortality due to coronary heart disease
• Osteoporosis
• Dementia and cognitive dysfunction
• Depression and anxiety

In premenopausal women:

• More severe and prolonged vasomotor symptoms-
• Reduction in libido and sexual dysfunction

Question 8

Outline the anatomical parts of the urinary tract in relation to the pelvis where injuries are most commonly described during hysterectomy (4 marks):

Answer 8

• Ureter runs into pelvis posterior and medial to the infundibulopelvic ligament
• The ureters then descend into the pelvis within a peritoneal sheath (ureteric fold) attached to the medial leaf of the uterine broad ligament and the lateral pelvic sidewall.
• Ureter crosses behind the uterine arteries bilateral approximately 1.5 cm lateral to the internal cervical os.
• The ureter passes through the areolar tissue of the tunnel of Wertheim (ie, the cardinal ligament/anterior bladder pillar) to the anterolateral surface of the cervix
• Bladder