A hysterectomy can be performed in different ways:
Additionally, a distinction is made between a total hysterectomy with preservation of the cervix and a supracervical hysterectomy.
Uterine fibroids, fibroids are the most common indication for a hysterectomy, approximately 75% of all hysterectomies.
Bleeding disorders
Adenomyosis uteri
Endometriosis
Genital prolapse
Precancerous changes of the endometrium and cervix
Suspicious changes indicating a malignancy
The occurrence of an incidental uterine sarcoma during a hysterectomy or myomectomy ranges between 1/205 and 1/7400 (0.49%-0.014%). In a meta-analysis of 10,120 patients, a frequency of 0.29% was found. Due to this risk, there was a withdrawal of electromechanical morcellators, by Ethicon in 2014 and Karl Storz in 2021.
In imaging, there is no reliable preoperative distinction between benign and malignant findings. However, clinical examinations, "soft markers" in transvaginal ultrasound, possibly MRI, and a detailed medical history can likely reduce the risk. Benign uterine fibroids do not contraindicate morcellation. Therefore, it is important to preoperatively inform about the potential dangers of morcellation, alternative approaches and their respective perioperative risks (morbidity and mortality of other surgical techniques), and on the other hand, the low incidence of sarcomas.
The use of retrieval bags also cannot exclude the dissemination of tumor cells. There are different techniques of morcellation:
Manual in bag Morcellation: Insertion of the retrieval bag, luxation of the uterus into it, minilaparotomy, and fragmentation using a scalpel (extra-abdominal).
Contained power Morcellation: Insertion of a retrieval bag, luxation of the uterus into it, electromechanical morcellation within the bag (intra-abdominal).
No morcellation should be performed in postmenopausal patients with newly developed fibroids or fibroids with a tendency to grow or newly symptomatic fibroids.
Conducting an adequate medical history and a gynecological examination. The examination is intended to identify other pathologies of the uterus or adnexa, in order to possibly avoid a hysterectomy (e.g., submucosal fibroids or pedunculated fibroids, polyp of the corpus uteri). Additionally, determination of the actual level of distress and information about alternative treatment options.
Laboratory examination (depending on the needs of the clinic)
Further examinations (MRI, CT) are only useful with appropriate indications.
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