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Total vs Subtotal
AN UNSOLVED PROBLEM?
G Centini, E Zupi, A Wattiez
Hysterectomy
Total vs Subtotal Hysterectomy
• 153 patient with 15 years of follow-up
Total vs Subtotal Hysterectomy
1843
The Timeline…
The first documented hysterectomy world wide.
(Subtotal)!Charles Clay!!
The patient died from massive hemorrhage
1960
First Laparoscopic Hysterectomy!Harry Reich
First Laparoscopic Subtotal Hysterectomy!
Semm
19881853
The first successful hysterectomy (Subtotal)!!
Walter Burnham!
19401929
From 1840 to 1940 subtotal hysterectomy was the standard procedure!
1940 to 1960 debate on cervix removal to avoid cervical
cancer!
The first successful total hysterectomy!!Richardson!
1991
From the 90’s till now we are debating the possible
advantages of SHPap Smear
Total vs Subtotal Hysterectomy
vs
RCT Anatomy
Total vs Subtotal Hysterectomy
• No difference in prevalence of stress urinary incontinence (OR 1,45; 2 Studies)
• No difference in sexual satisfaction or dyspareunia (4 Studies)
• The duration of surgery is shorter, only the abdominal approach is significant (LPT - 11 min; LPS - 5 min)
• Significantly less blood loss (- 56 ml, 3 Studies)
• Significantly less postoperative pyrexia (OR 0.48, 5 Studies) and urinary retention (OR 0.23, 5 Studies)
• Author Conclusion: The results are inconclusive to sustain the superiority of SH. After SH patients are more likely to experience cyclical bleeding
The Cochrane Library 2012, Issue 4
Total vs Subtotal Hysterectomy
• Additional procedures do not reduce the risk of post-op bleeding (Level B)
• Short-term sexual outcomes may be improved (Level B)
• No data demonstrate difference in bladder or bowel function (Level B)
• The risk of cervical malignancy is low and should not be considered a deterrent (Level B)
JMIG, 2014
• No evidence that SH is protective against future POP
Total vs Subtotal Hysterectomy
• Mean Age: 46 at baseline; 57 at follow up
• 184 Patients with a mean follow up of 10 years
• Prolapse Surgery: 1% in the SH vs 3,5% in TH
• POP- Q: Point D and Total vaginal length longer in the SH group
• Author Conclusion : No significant differences. Larger group and longer follow up are necessary.
Total vs Subtotal Hysterectomy
• Prospective cohort study of 122 patients, follow-up 1 month
JMIG, 2011
Total vs Subtotal Hysterectomy
Uterosacral Ligament, Upper
part of the paracervix
Pelvic Organs Suspension
Level I:
Level II:
Level III:
Pubocervical Fascia,
Rectovaginal Fascia
Perineal membrane,
levator ani
De Lancey 2004
Total vs Subtotal Hysterectomy
Apical prolapse, the cervix or the cuff can move downward
Pelvic Organs Suspension
Defects of Level I:
De Lancey 2004
Total vs Subtotal Hysterectomy
• The USL plays an important role in pelvic organs support
Total vs Subtotal HysterectomyVaginal Innervation
Total vs Subtotal HysterectomyUterus and vaginal apex innervation
Total vs Subtotal Hysterectomy
Total vs Subtotal HysterectomyBladder Innervation
Sympathetic
Parasympathetic
Total vs Subtotal HysterectomyContraindication for Subtotal Hysterectomy
• Subtotal Hysterectomy should not be performed in cases of Endometriosis or Prolapse
…these conditions occur in less than 2 % of cases
However, the average time for reintervention (trachelectomy) is 26 years
Total vs Subtotal HysterectomyContraindication for Subtotal Hysterectomy
The retrocervical localization is very frequent and is better to remove the cervix than leave disease
Total vs Subtotal HysterectomyIndication for Subtotal Hysterectomy
Performing a colposacropexy Subtotal Hysterectomy is
associated with reduced rate of complication
Total vs Subtotal HysterectomyMorcellation
Courtesy of Prof. Charles Miller
Total vs Subtotal HysterectomyConclusions
• Subtotal Hysterectomy should be included in the decisional process while counseling the patient
• Subtotal Hysterectomy should be performed if a colposacropexy is scheduled
• Subtotal Hysterectomy should not be performed in case of Endometriosis or Prolapse
• The patient has to be informed about the risk of cyclic bleeding and cervical screening
Grazie per l ’attenzione !!
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