Special Feature: Total or Subtotal Hysterectomy: Which is Superior?

By Frank W. Ling, MD

As the "new kid on the OB/GYN Clinical Alert block," and as the generalist among the editors, I intend to focus on topics that come up commonly in my own practice of obstetrics and gynecology. The beauty of having this format is that cutting edge science can be presented, but also sacred cows can be challenged.

So our topic this time around is the most common major gynecologic surgical procedure in the United States, the hysterectomy. Stimulus for this discussion was provided in the New England Journal of Medicine in which Thakar and colleagues looked at the outcome of 279 benign cases randomized to either subtotal or total abdominal hysterectomy.1 Total hysterectomy was associated with longer operating time, more blood loss, longer hospitalization, more postoperative fever, and more frequent use of antibiotics. One-year follow-up revealed some complications more commonly associated with subtotal hysterectomy (cyclic vaginal bleeding, 6.8%; persistent pelvic pain, 2.3%; and cervical prolapse, 1.5%) and some with total hysterectomy (bowel obstruction, 1.4% and pelvic pain, 4.8%).

Of great interest to our patients are the following findings in both groups: 1) the incidence of bowel dysfunction did not increase over the preoperative state; 2) the incidence of lower urinary tract dysfunction decreased after surgery; 3) frequency of intercourse increased after surgery; 4) prevalence of deep dyspareunia declined after surgery; and 5) orgasms did not change from baseline.

These data should reinforce to each of us who performs hysterectomy the potential effect of how we counsel our patients regarding the surgical approach that we recommend. As gynecologic surgeons we are in a unique position to truly improve quality of life. Unlike other surgical specialties in which the doctor-patient relationship may well be limited to the procedure and the immediate postoperative period, ours is a lasting one. We will continue to see our surgical patients for both specific concerns as well as health care maintenance. It should be reassuring to both us and our patients that abdominal hysterectomy, either total or subtotal, does not appear to be associated with an increased incidence of problems related to gastrointestinal, urinary, or sexual functioning.

As an extension of these findings, each of us should also be reassessing what we recommend to our patients regarding which type of hysterectomy to have (total vs subtotal/supracervical) as well as what approach should be taken (abdominal vs vaginal vs laparoscopic-assisted vs laparoscopic). I raise these issues here because the data that can help us guide our patients must be based on sound evidence and not anecdotal information. Remember: not all publications are created equal. It is a good thing that our peer-reviewed literature provides an opportunity for a novel approach to be described or a series of satisfied patients to be reported. Neither of these examples, however, should necessarily change our pattern of care. Similarly, articles on "My favorite approach to . . ." or "How I perform . . ." in nonpeer-reviewed journals should not convince us or our patients to question established care. It is, however, a bad thing if choices of patient care on based upon inappropriate claims of superiority or inadequate data.

The discriminating consumer and the astute clinician cannot avoid being exposed to claims that supracervical hysterectomy is superior to total hysterectomy in terms of sexual functioning and organ prolapse. Is it true? It certainly has not been proven. By the same token, who has the experience to say that it isn’t? Answer: Nobody. There are no definitive data to support or refute the claim. Our job as both the surgeon and patient advocate should be to make sure that the patient truly is given informed consent about the risk and benefits of both, and that her concerns and preferences are fully addressed. One hint to keep perspective: If you feel as though you’re "selling" an operation, you probably are. Back up half a step and make sure that the informed consent is balanced and based on what we know. It remains a privilege to have women trust us as their surgeon and physician. These patients deserve the best that we can do, both in the operating room as well as in the office counseling session.

Reference

1. Thakar, R, et al. Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med. 2002;347: 1318-1325.