Total or subtotal abdominal hysterectomy for benign gynaecological disease

Abstract

Hysterectomy, the commonest major gynaecological operation in both the UK and the US, is the only definitive cure for dysfunctional uterine bleeding, rates highest in satisfaction scores compared to other treatments, and improves quality of life. The majority are performed by the abdominal route, and in both countries the majority are total, the subtotal procedure accounting for less than 5%. Research from Scandinavia in the early 1980s suggesting that subtotal hysterectomy might be advantageous in terms of bladder and sexual function sparked off a vigorous debate and controversy on total versus subtotal hysterectomy. This debate has recently been largely resolved by a large prospective, double-blind multi-centre trial showing no major advantage for one operation over the other in terms of pelvic organ function, although longer-term data is required to resolve issues on vault/cervical stump prolapse, and to establish whether the beneficial effects of both operations on bladder and sexual function persist long term. As conservative alternatives to hysterectomy, including endometrial ablative techniques, the Mirena Intrauterine System (IUS) and uterine artery embolisation (UAE) for fibroids, have not greatly reduced hysterectomy rates, other issues should now be addressed. These include the reasons for the wide variation in hysterectomy rates between regions, and within the same geographical areas. Rigorous research is also required on abdominal versus vaginal hysterectomy in the absence of prolapse, and an evaluation of UAE versus hysterectomy and myomectomy is essential, since uterine fibroids are the commonest indication for hysterectomy.