Evidence - Supracervical hysterectomy, bilateral salpingectomy, laparoscopic

Benign Conditions: Uterine fibroids (~50%), abnormal uterine bleeding (~40%), pain (e.g., in endometriosis/adenomyosis (~30%) or pelvic inflammatory diseases), uterine prolapse (~18%), 

Malignant Conditions: Cervical, endometrial, ovarian cancer, and pre-invasive diseases.

There are conservative and surgical alternatives to hysterectomy, depending on the underlying condition. For example, uterine fibroids can be treated with uterine artery embolization and myomectomy. Pelvic organ prolapse can be managed with conservative therapies such as pelvic floor exercises or pessaries. Chronic pelvic pain can be managed through pain control interventions, including hormonal therapy. Heavy menstrual bleeding can be treated with medical therapies, endometrial ablation, or intrauterine devices. Endometriosis and endometrial hyperplasia can often be treated medically, while cervical intraepithelial neoplasia may be adequately treated by conization. 

Reference: 

1. Whiteman MK, Hillis SD, Jamieson DJ, Morrow B, Podgornik MN, Brett KM, et al. Inpatient hysterectomy surveillance in the United States, 2000–2004. Am J Obstet Gynecol 2008;198:34.e1–7.
2. Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu YS, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol 2013;122:233–41.
3. Merrill RM. Hysterectomy surveillance in the United States, 1997 through 2005. Med Sci Monit 2008; 14:CR24.
4. Walker JL, Piedmonte MR, Spirtos NM, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol 2009; 27:5331.
5. Walker JL, Piedmonte MR, Spirtos NM, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol 2012; 30:695.
6. Weber S, McCann CK, Boruta DM, et al. Laparoscopic surgical staging of early ovarian cancer. Rev Obstet Gynecol 2011; 4:117.
7. Ramirez PT, Soliman PT, Schmeler KM, et al. Laparoscopic and robotic techniques for radical hysterectomy in patients with early-stage cervical cancer. Gynecol Oncol 2008; 110:S21.

The choice of surgical approach depends on several factors, including the size and location of the uterus, the need for simultaneous exploration of surrounding pelvic organs, and the patient's medical history.

Before the operation, several questions should be considered: 

1. Can the uterus be retrieved vaginally?
2. Is the indication for surgery (disease) limited to the uterus? Or are other intra-abdominal changes suspected, such as endometriosis, adhesions, changes in the ovaries?
3. Are many intra-abdominal adhesions suspected? 
4. Is a supracervical hysterectomy or a total hysterectomy planned?
5. Are there contraindications for Trendelenburg position or increased intraperitoneal pressure?
6. What is the surgeon's training and experience?

Conditions outside the uterus such as adnexal pathology, severe endometriosis, adhesions, or an enlarged uterus could be contraindications for a vaginal hysterectomy. In these cases, however, another minimally invasive approach may be possible instead of an open abdominal approach. At the beginning of the procedure, a laparoscopic assessment of the pelvis can be performed to evaluate the feasibility of a minimally invasive approach.

The obstetrician-gynecologist should discuss the options with the patients and provide clear recommendations on which type of hysterectomy offers the greatest benefit and minimizes risks given the specific clinical situation.

Between 2008 and 2018, the rates for vaginal hysterectomies decreased from 51 to 13 percent, while the rates for total laparoscopic hysterectomies increased from 12 to 68 percent. Contrary to this trend, evidence supports the view that (when feasible) vaginal hysterectomy is associated with better outcomes and is the most cost-effective method to remove the uterus.

The vaginal hysterectomy: is considered the method with the fastest recovery time and the least postoperative complications.

Laparoscopic (minimally invasive): 

• In a total laparoscopic hysterectomy, the uterus and cervix are removed. 
• In a laparoscopic subtotal (supracervical) hysterectomy, only the uterus is removed. 
• Laparoscopically-assisted vaginal hysterectomy. In laparoscopically-assisted vaginal hysterectomy, a total hysterectomy is performed, with the remainder of the procedure carried out vaginally.
• The robot-assisted surgery offers enhanced precision and flexibility but is costly and requires specialized training.
• V-NOTES combines vaginal access with minimally invasive surgery.

Minimally invasive procedures are less invasive and generally lead to faster recovery and less postoperative pain, shortening hospital stays and postoperative recovery times compared to open abdominal hysterectomy. 

The abdominal hysterectomy is preferred for extensive cases or when the uterus is significantly enlarged, but it results in a longer recovery time and increased postoperative pain.

Minimally invasive approaches to hysterectomy (vaginal or laparoscopic, including robot-assisted laparoscopy) should be performed whenever possible due to their well-documented advantages over abdominal hysterectomy.

Vaginal hysterectomy compared to abdominal hysterectomy:

• Shorter hospital stay, quicker return to normal activity, less pain, no difference in satisfaction, intraoperative injury, or complications.

Vaginal hysterectomy compared to laparoscopic hysterectomy:

• Shorter operation time, lower overall costs, higher patient satisfaction, less frequent vaginal cuff dehiscence, lower risk of urinary tract injury, no differences in return to normal activities or complications, 

Laparoscopic hysterectomy compared to abdominal hysterectomy:

• Faster return to normal activity, shorter hospital stay, fewer wound or abdominal wall infections, longer operation time, higher rate of lower urinary tract injuries, improved postoperative quality of life, no differences in satisfaction or major long-term complications, no differences in overall costs.

Laparoscopic hysterectomy compared to robot-assisted laparoscopic hysterectomy:

• Few differences in measured outcomes

Laparoscopic hysterectomy compared to V-Notes

• less postoperative pain, faster recovery, and improved cosmetic results

1. Luchristt D, Brown O, Kenton K, Bretschneider CE. Trends in operative time and outcomes in minimally invasive hysterectomy from 2008 to 2018. Am J Obstet Gynecol 2021; 224:202.e1.
2. Dorsey JH, Holtz PM, Griffiths RI, McGrath MM, Steinberg EP. Costs and charges associated with three alternative techniques of hysterectomy [published erratum appears in N Engl J Med 1997;336:147]. N Engl J Med 1996;335: 476–82
3. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol 2011; 18:1.
4. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015; :CD003677.
5. Committee Opinion No 701: Choosing the Route of Hysterectomy for Benign Disease. Obstet Gynecol 2017; 129:e155.
6. Sandberg EM, Twijnstra AR, Driessen SR, Jansen FW. Total Laparoscopic Hysterectomy Versus Vaginal Hysterectomy: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2017; 24:206.
7. Baekelandt J, De Mulder PA, Le Roy I, et al. Postoperative outcomes and quality of life following hysterectomy by natural orifice transluminal endoscopic surgery (NOTES) compared to laparoscopy in women with a non-prolapsed uterus and benign gynaecological disease: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2017; 208:6.

Opportunistic salpingectomy, also an oncological prophylactic salpingectomy for ovarian cancer reduction. Approximately 7,000 women are diagnosed with ovarian cancer annually in Germany. In most cases, the cancer is detected at an advanced stage (FIGO III-IV, about 70%), resulting in a poor prognosis. Additionally, there is no good early detection method.

In 2010, the British Columbia Ovarian Cancer Research (OVCARE) team proposed prophylactic salpingectomy as a strategy for primary prevention of ovarian cancer, based on the following observations:

• Carcinogenesis: Most ovarian carcinomas, especially high-grade serous carcinoma, originate from the epithelium of the distal fallopian tube rather than the ovary itself.
• In patients at high risk for ovarian cancer (e.g., patients with BRCA1 and BRCA2 mutations), risk-reducing bilateral salpingo-oophorectomy was performed, where occult tubal carcinomas and/or premalignant lesions were found in the fallopian tube, which were not found in the ovary.
• Premalignant lesions were also found in the fallopian tubes of patients with average risk. Here, salpingectomy was performed for benign reasons, such as sterilization or hysterectomy.
• It was shown that the involvement of the fallopian tubes was present in up to 75 percent of patients diagnosed with ovarian or primary peritoneal serous carcinoma (with and without BRCA mutations), including the presence of fimbrial precancers up to 60 percent.
• Tubal ligation can also reduce the risk of ovarian cancer, with large retrospective studies showing a greater risk reduction for non-serous histologies (particularly endometrioid and clear cell carcinomas).

Mechanisms of risk reduction:

• Removing the initial site of carcinogenesis (high-grade serous carcinomas)
• Removing the tube for the passage of endometriotic or endosalpingiotic cells (clear cell and endometrioid carcinomas)
• Removing the tube for the passage of carcinogens (e.g., talc) or inflammation (e.g., pelvic infection) before reaching the ovary.

The indication for bilateral opportunistic salpingectomy should only be made for patients undergoing pelvic surgery for another reason (e.g., hysterectomy for benign disease, permanent sterilization) and who have completed family planning. In patients at high risk for cancers of the fallopian tube, ovary, and peritoneum (e.g., BRCA gene mutation, Lynch syndrome), a risk-reducing bilateral salpingo-oophorectomy should be performed after a benefit-risk assessment.

Many studies have examined the perioperative course after an opportunistic salpingectomy:

• Extension of surgery time by approximately 10-16 minutes
• Blood loss: no difference
• Hospital stay: no difference
• Perioperative complications (infections, blood draws, rounds, further diagnostics): no difference
• Menopause: Onset of menopause was the same in both groups. However, one study showed that the Anti-Müllerian hormone was slightly lower in the salpingectomy group.

Risk reduction of developing ovarian cancer:

A meta-analysis showed that with a follow-up period of 18-36 years, prophylactic bilateral salpingectomy versus no salpingectomy reduced the risk by almost 50 percent, adjusted for the study population. Overall, the risk of developing ovarian cancer was very low in both groups (0.8 and 0.7 percent, respectively).

Reference:

1. Center for Cancer Registry Data: Ovarian Cancer (Ovarian Carcinoma). www.krebsdaten.de/Krebs/DE/Content/Krebsarten/Eierstockkrebs/eierstockkrebs_node.html (last accessed on 7 February 2022).
2. Homepage. OVCARE. Available at: www.ovcare.ca (Accessed on September 08, 2021).
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6. Tobacman JK, Greene MH, Tucker MA, et al. Intra-abdominal carcinomatosis after prophylactic oophorectomy in ovarian-cancer-prone families. Lancet 1982; 2:795.
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8. Struewing JP, Watson P, Easton DF, et al. Prophylactic oophorectomy in inherited breast/ovarian cancer families. J Natl Cancer Inst Monogr 1995; :33.
9. Powell CB, Chen LM, McLennan J, et al. Risk-reducing salpingo-oophorectomy (RRSO) in BRCA mutation carriers: experience with a consecutive series of 111 patients using a standardized surgical-pathological protocol. Int J Gynecol Cancer 2011; 21:846.
10. Powell CB, Swisher EM, Cass I, et al. Long term follow up of BRCA1 and BRCA2 mutation carriers with unsuspected neoplasia identified at risk reducing salpingo-oophorectomy. Gynecol Oncol 2013; 129:364.
11. Reitsma W, de Bock GH, Oosterwijk JC, et al. Support of the 'fallopian tube hypothesis' in a prospective series of risk-reducing salpingo-oophorectomy specimens. Eur J Cancer 2013; 49:132.
12. Wethington SL, Park KJ, Soslow RA, et al. Clinical outcome of isolated serous tubal intraepithelial carcinomas (STIC). Int J Gynecol Cancer 2013; 23:1603.
13. Finch A, Shaw P, Rosen B, et al. Clinical and pathologic findings of prophylactic salpingo-oophorectomies in 159 BRCA1 and BRCA2 carriers. Gynecol Oncol 2006; 100:58.
14. Medeiros F, Muto MG, Lee Y, et al. The tubal fimbria is a preferred site for early adenocarcinoma in women with familial ovarian cancer syndrome. Am J Surg Pathol 2006; 30:230.
15. Colgan TJ, Murphy J, Cole DE, et al. Occult carcinoma in prophylactic oophorectomy specimens: prevalence and association with BRCA germline mutation status. Am J Surg Pathol 2001; 25:1283.
16. Callahan MJ, Crum CP, Medeiros F, et al. Primary fallopian tube malignancies in BRCA-positive women undergoing surgery for ovarian cancer risk reduction. J Clin Oncol 2007; 25:3985.
17. Gilks CB, Irving J, Köbel M, et al. Incidental nonuterine high-grade serous carcinomas arise in the fallopian tube in most cases: further evidence for the tubal origin of high-grade serous carcinomas. Am J Surg Pathol 2015; 39:357.
18. Morrison JC, Blanco LZ Jr, Vang R, Ronnett BM. Incidental serous tubal intraepithelial carcinoma and early invasive serous carcinoma in the nonprophylactic setting: analysis of a case series. Am J Surg Pathol 2015; 39:442.
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Overall complication rates for laparoscopic hysterectomy in benign conditions range between 4 and 14 percent. An English study demonstrated that adhesions and adenomyosis were associated with an increased risk of severe complications during laparoscopic hysterectomy (adjusted odds ratios of 1.92, 95% confidence interval 1.73-2.13 and 1.46, 95% confidence interval 1.36-1.60, respectively).

Infections: Laparoscopic hysterectomy is associated with a 3 percent risk of infections in the surgical area, mostly wound infections. Deeper infections or abscesses are very rare <1%. Compared to abdominal hysterectomy, febrile episodes, wound infections, or abdominal wall infections occur less frequently.

Conversion to laparotomy: The conversion rate is approximately 3.9 percent, depending on the complexity of the procedure.

Urinary tract injury: The incidence is between 1.2 and 2.6 percent. A study from Norway examined ureteral injuries, which were 1.2% in laparoscopic hysterectomy and 1% in laparotomy.

Vaginal cuff dehiscence: The incidence is between 0.64 and 1.64 percent. Historically, the incidence after laparoscopic procedures, including robot-assisted surgeries, was described as the highest. However, a review and meta-analysis showed that dehiscence after total laparoscopic hysterectomy was between 0.64 and 1.35 percent, with robot-assisted hysterectomy associated with an incidence of 1.64 percent.

Bowel injury: Incidence is between 0.34 and 0.45 percent.

1. Pepin KJ, Cook EF, Cohen SL. Risk of complication at the time of laparoscopic hysterectomy: a prediction model built from the National Surgical Quality Improvement Program database. Am J Obstet Gynecol 2020; 223:555.e1.
2. Catanzarite T, Saha S, Pilecki MA, et al. Longer Operative Time During Benign Laparoscopic and Robotic Hysterectomy Is Associated With Increased 30-Day Perioperative Complications. J Minim Invasive Gynecol 2015; 22:1049.
3. Madhvani K, Garcia SF, Fernandez-Felix BM, et al. Predicting major complications in patients undergoing laparoscopic and open hysterectomy for benign indications. CMAJ 2022; 194:E1306.
4. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev 2015; :CD003677.
5. Mahdi H, Goodrich S, Lockhart D, et al. Predictors of surgical site infection in women undergoing hysterectomy for benign gynecologic disease: a multicenter analysis using the national surgical quality improvement program data. J Minim Invasive Gynecol 2014; 21:901.
6. Lim CS, Mowers EL, Mahnert N, et al. Risk Factors and Outcomes for Conversion to Laparotomy of Laparoscopic Hysterectomy in Benign Gynecology. Obstet Gynecol 2016; 128:1295.
7. Wong JMK, Bortoletto P, Tolentino J, et al. Urinary Tract Injury in Gynecologic Laparoscopy for Benign Indication: A Systematic Review. Obstet Gynecol 2018; 131:100.
8. Ravlo M, Moen MH, Bukholm IRK, et al. Ureteric injuries during hysterectomy-A Norwegian retrospective study of occurrence and claims for compensation over an 11-year period. Acta Obstet Gynecol Scand 2022; 101:68.
9. Hur HC, Donnellan N, Mansuria S, et al. Vaginal cuff dehiscence after different modes of hysterectomy. Obstet Gynecol 2011; 118:794.
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In a laparoscopically performed hysterectomy, the uterus can be removed either intact, as a whole, or in smaller pieces following scalpel or power morcellation. Power morcellation in gynecological surgery has been critically viewed due to concerns about the risk of intraperitoneal spread of malignant tissue, particularly uterine sarcomas.

It is well documented that minimally invasive surgical techniques for hysterectomy reduce the risk of surgical morbidity. The risk of death from disseminated cancer associated with laparoscopic hysterectomy with power morcellation must be weighed against the increased risk of morbidity and hysterectomy-related deaths in open abdominal hysterectomy.

In a supracervical hysterectomy, it has been shown that the operation time could be slightly reduced compared to a complete hysterectomy, but at the same time, it must be weighed against the potential need for future treatment of cervical cancer or cervical bleeding.

In a 2012 review, no differences were found between the groups in terms of urinary, bowel, or sexual function, recovery from surgery, complications, readmission rate, or transfusion. Disadvantages of a supracervical hysterectomy include the ongoing need for cancer screening and cyclical vaginal bleeding, and in some cases, cervical stump removal was necessary.

In another study, it was shown that there were no differences in urinary incontinence, genital descent, and prolapse symptoms between women who underwent supracervical or total hysterectomy. Data were collected over 14 years post-operation.

An advantage of supracervical hysterectomy could be that it provides a better fixation point in descent surgery; additionally, the patient might prefer a supracervical hysterectomy for personal or sexual reasons.

1. AAGL. AAGL statement to the FDA on power morcellation. Available at: https://www.aagl.org/aaglnews/aagl-statement-to-the-fda-on-power-morcellation. Retrieved February 7, 2017.
2. Siedhoff MT, Wheeler SB, Rutstein SE, Geller EJ, Doll KM, Wu JM, et al. Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroid tumors in premenopausal women: a decision analysis. Am J Obstet Gynecol 2015;212:591.e1–8.
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