hysterectomy
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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. - PowerPoint PPT PresentationTRANSCRIPT
Hysterectomy for Undergraduates
Max Brinsmead MB BS PhD
May 2015
Indications for Hysterectomy
Fibroids Menstrual dysfunction Prolapse Endometriosis Adenomyosis Pelvic Inflammatory Disease Cancer
Cervix Uterus Ovaries
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
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
Routes for Hysterectomy
Abdominal Hysterectomy (AH) Total Subtotal
Vaginal Hysterectomy (VH)
Laparoscopic Hysterectomy Laparoscopically-assisted vaginal (LAVH) Totally laparoscopic hysterectomy
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 Longest operating time But shortest hospitalisation and recovery But has the greatest overall risk of complications There is debate about its cost effectiveness
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
“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
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
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
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
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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