Treatment of Uterine Pathology: When Is Simple Hysterectomy Indicated?

Introduction

Hysterectomy is the most common gynecological operation after cesarean section. (Dorsey, 1995) The majority of hysterectomies are performed for the treatment of benign diseases which, although are not life-threatening, have a negative impact in the quality of patients’ life. During recent years the indications of hysterectomy tend to diminish due to more conservative approach for this kind of diseases. Abnormal uterine bleeding, the most common indication for hysterectomy, most of the times is dysfunctional and not a result of endometrial pathology. Thus, there is a decrease of the procedures of hysterectomy the past decades and a tendency to conservative approach to women with abnormal uterine bleeding.

The final decision of proposing a hysterectomy as a treatment choice, as well as the type of surgical approach should take into account several parameters as midterm and long-term benefits for the patient, the good quality of life and the cost-effectiveness of each approach. Subtotal hysterectomies were common during last century but now it is abandoned mainly due to the risk of cervical cancer. In addition, there is no evidence of better sexual function or reduced risk of pelvic floor prolapse as it was believed. (Lefebvre, 2018) Vaginal hysterectomy meets most of the times the described criteria, especially when is combined with laparoscopy in comparison to laparotomy. It is the least operative technique, with cost-effectiveness, with less complications and a shorter hospitalization (Kovac, 2000). Other parameters that must be taken into account are the specific indication, the size and morphology of the uterus that will be removed, the will of the patient for fertility sparing treatment, the existence of disease outside the uterus, the equipment and education of the health providers, the surgical history of the patient as well as the emergency of the operation (Wright, 2013). Laparoscopic hysterectomy is superior to laparotomy, when a vaginal hysterectomy is contraindicated. The role of robotically assisted laparoscopic hysterectomy is not evaluated and we need further experience and search in this field. Nonetheless, in clinical practice, open hysterectomy is the most common type of procedure representing 60-70% of hysterectomies for benign diseases.

Abnormal uterine bleeding is the most common indication for hysterectomy in premenopausal women and is usually a result of myomas and adenomyosis. Another indication is chronic pelvic pain that is usually caused by endometriosis and/or adenomyosis. In the USA the most common benign situations that lead to hysterectomy are myomas causing symptoms (51,4%), dysfunctional vaginal bleeding (41,7%), endometriosis (30%) and uterine prolapse (18,2%) (Backes, 2014). As far as malignancies and obstetric indications are concerned, they represent less than 10% of the cases (Lethaby, 2015).

There are several complications that can occur post-operatively in a patient that undergoes hysterectomy. All patients, regardless the indication for the surgery, should be thoroughly informed before consenting to hysterectomy. The majority of minor complications are fever, hemorrhage and infection. (Lefebvre, 2018) In addition there are lots of possible anatomical complications such as injuries to the urinary bladder, ureter, intestines, rectum, anus, and a multitude of nervous structures. Other complications are also recorded as sexual dysfunction, vaginal cuff prolapse and urinary incontinence. (Ramdhan, 2017)