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Hysterectomy

Hysterectomy. Max Brinsmead PhD FRANZCOG September 2012. Indications for Hysterectomy. Fibroids Menstrual dysfunction Prolapse Endometriosis Adenomyosis Pelvic Inflammatory Disease Cancer Cervix Uterus Ovaries. Alternatives to Hysterectomy.

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Hysterectomy

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  1. Hysterectomy Max Brinsmead PhD FRANZCOG September 2012

  2. Indications for Hysterectomy • Fibroids • Menstrual dysfunction • Prolapse • Endometriosis • Adenomyosis • Pelvic Inflammatory Disease • Cancer • Cervix • Uterus • Ovaries

  3. Alternatives to Hysterectomy • Medical treatment of bleeding problems or endometriosis • Endometrial resection for menorrhagia • Myomectomy and uterine artery embolisation for fibroids • Radiotherapy for Ca cervix • A number of RCT’s and systematic analyses compare these alternatives • So clinician-guided and informed patient choice is an important component of best practice

  4. Types of Hysterectomy • Subtotal Hysterectomy • Uterine body only • Total Hysterectomy • Uterine body and cervix (not ovaries!) • Hysterectomy with BSO • Uterus with bilateral salpingo oophorectomy • Radical (or Wertheim) Hysterectomy • Total hysterectomy with pelvic lymph nodes, paracervical tissue and upper 1/3 vagina

  5. Routes for Hysterectomy • Abdominal Hysterectomy (AH) • Total • Subtotal • Vaginal Hysterectomy (VH) • Laparoscopic Hysterectomy • Laparoscopically-assisted vaginal (LAVH) • Totally laparoscopic hysterectomy

  6. Which Route is Best? • Abdominal Hysterectomy • Results in greatest mean blood loss • Has the highest incidence of febrile morbidity • And abdominal wound infection (obviously) • Longest hospitalisation • And slowest to recover • Vaginal Hysterectomy • Is the preferred route when technically possible • Laparoscopic Hysterectomy • Requires training and equipment • Longetest operating time • But shortest hospitalisation and recovery • But has the greatest overall risk of complications • There is debate about its cost effectiveness

  7. Complications of Hysterectomy • Infection • Abdominal incision • Vaginal vault and pelvic • Infected haematoma • Blood loss and anaemia • Bladder dysfunction or Cystitis • Bowel dysfunction • Damage to: • Bladder • Bowel • Ureters • Depression or Sexual Dysfunction • Longer Term • Prolapse • Wound pain • Earlier menopause

  8. “Ball-Park” Risks with Hysterectomy • 30 – 40% minor complication rate • 1:10 risk of “unpleasant” complication • 1:20 risk of transfusion • 1:50 risk of serious complication • But <1:100 with ongoing problems • 1-3:1000 risk of death • Complications are some 1.5-fold more common if there are fibroids

  9. Removal of the Cervix • Is only an option during abdominal hysterectomy • Technically more difficult • So operative time and blood loss is increased • But a good option when things are going badly • Some evidence for more bladder problems when it is left (about 2-fold) • Sometimes “mini periods” if it is left (about 7%) • 2% risk of cervical prolapse when it is left • Main argument for removal is risk of CIN and Ca • But the cervix does not have any sexual function • Confirmed by RCTs

  10. Bilateral Oophorectomy during Hysterectomy? • 1:80 lifetime risk of ovarian cancer • Bilateral oophorectomy reduces the risk of breast Ca • Is more important for the woman at risk • e.g. those with BRAC1&2 mutations • But up to 1:10 pre menopausal women undergoing hysterectomy return for surgery to remaining ovaries • This can be technically difficult • And PMT-symptoms can be a major problem for a few women • Oophorectomy may be important if there is peritoneal endometriosis • Adds little to operative time and risk during AH • But may be quite difficult in up to 30% during VH

  11. Bilateral Oophorectomy during Hysterectomy 2? • The major problem is that of premature menopause • And symptoms from a surgical menopause seem to be more severe • Many women feel very strongly about ovarian removal • And there is a dearth of information about any endocrine role for postmenopausal ovaries • They continue to produce androgens • Which may have a role in well-being and libido • And are converted to oestrone by fat cells • Age is one factor that has a major role in deciding about bilateral oophorectomy • Below the age of 45 – aim for preservation • Above the age of 65 – balance tips in favour of removal

  12. After Hysterectomy • Most women don’t need Pap smears • Except those who had previous CIN >2 , Ca Cervix or Ca corpus uterus • Oestrogen only HRT (ERT) is an option • Except when BSO was performed for oestrogen responsive cancer or severe endometriosis • Symptoms control in these patients can be a real problem • Current research suggests that ERT has many benefits and few risks

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