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Choosing a route of hysterectomy for benign disease

Mark D Walters, MD
Section Editor
Howard T Sharp, MD
Deputy Editor
Kristen Eckler, MD, FACOG


Hysterectomy can be performed vaginally, abdominally, laparoscopically, or with robot-assisted laparoscopy. Hysterectomy can also be performed by combining two of these four routes, such as in laparoscopically-assisted vaginal hysterectomy or laparoscopic hysterectomy combined with a mini-laparotomy to remove the uterine specimen from the peritoneal cavity. Hysterectomy has been associated with improvements in physical and mental quality-of-life measures, body image, and aspects of sexual activity, with few differences among surgical routes [1,2].

This topic review will review the data and clinical issues that impact selection of hysterectomy route. Topics on specific hysterectomy techniques are reviewed separately. (See "Vaginal hysterectomy" and "Laparoscopic hysterectomy" and "Abdominal hysterectomy" and "Prophylactic vaginal apex suspension at the time of hysterectomy".)


There are five broad diagnostic categories of indications for hysterectomy:

Uterine leiomyomas

Abnormal uterine bleeding

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Literature review current through: Nov 2017. | This topic last updated: Oct 06, 2017.
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  1. Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 2004; 328:129.
  2. Radosa JC, Meyberg-Solomayer G, Kastl C, et al. Influences of different hysterectomy techniques on patients' postoperative sexual function and quality of life. J Sex Med 2014; 11:2342.
  3. Broder MS, Kanouse DE, Mittman BS, Bernstein SJ. The appropriateness of recommendations for hysterectomy. Obstet Gynecol 2000; 95:199.
  4. Falcone T, Parker WH. Surgical management of leiomyomas for fertility or uterine preservation. Obstet Gynecol 2013; 121:856.
  5. Grigoriadis T, Valla A, Zacharakis D, et al. Vaginal hysterectomy for uterovaginal prolapse: what is the incidence of concurrent gynecological malignancy? Int Urogynecol J 2015; 26:421.
  6. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol 2011; 18:1.
  7. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015; :CD003677.
  8. Committee on Gynecologic Practice. Committee Opinion No 701: Choosing the Route of Hysterectomy for Benign Disease. Obstet Gynecol 2017; 129:e155.
  9. Sandberg EM, Twijnstra AR, Driessen SR, Jansen FW. Total Laparoscopic Hysterectomy Versus Vaginal Hysterectomy: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2017; 24:206.
  10. Paraiso MF, Ridgeway B, Park AJ, et al. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Am J Obstet Gynecol 2013; 208:368.e1.
  11. Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA 2013; 309:689.
  12. Pasic RP, Rizzo JA, Fang H, et al. Comparing robot-assisted with conventional laparoscopic hysterectomy: impact on cost and clinical outcomes. J Minim Invasive Gynecol 2010; 17:730.
  13. Reza M, Maeso S, Blasco JA, Andradas E. Meta-analysis of observational studies on the safety and effectiveness of robotic gynaecological surgery. Br J Surg 2010; 97:1772.
  14. Albright BB, Witte T, Tofte AN, et al. Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials. J Minim Invasive Gynecol 2016; 23:18.
  15. Lönnerfors C, Reynisson P, Persson J. A randomized trial comparing vaginal and laparoscopic hysterectomy vs robot-assisted hysterectomy. J Minim Invasive Gynecol 2015; 22:78.
  16. Tapper AM, Hannola M, Zeitlin R, et al. A systematic review and cost analysis of robot-assisted hysterectomy in malignant and benign conditions. Eur J Obstet Gynecol Reprod Biol 2014; 177:1.
  17. Kovac SR, Barhan S, Lister M, et al. Guidelines for the selection of the route of hysterectomy: application in a resident clinic population. Am J Obstet Gynecol 2002; 187:1521.
  18. Kovac SR. Hysterectomy outcomes in patients with similar indications. Obstet Gynecol 2000; 95:787.
  19. Kovac SR. Decision-directed hysterectomy: a possible approach to improve medical and economic outcomes. Int J Gynaecol Obstet 2000; 71:159.
  20. Shiota M, Kotani Y, Umemoto M, et al. Indication for laparoscopically assisted vaginal hysterectomy. JSLS 2011; 15:343.
  21. Benassi L, Rossi T, Kaihura CT, et al. Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial. Am J Obstet Gynecol 2002; 187:1561.
  22. Doucette RC, Sharp HT, Alder SC. Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol 2001; 184:1386.
  23. Tohic AL, Dhainaut C, Yazbeck C, et al. Hysterectomy for benign uterine pathology among women without previous vaginal delivery. Obstet Gynecol 2008; 111:829.
  24. Stovall TG, Ling FW, Crawford DA. Hysterectomy for chronic pelvic pain of presumed uterine etiology. Obstet Gynecol 1990; 75:676.
  25. Sheth SS, Malpani AN. Vaginal hysterectomy following previous cesarean section. Int J Gynaecol Obstet 1995; 50:165.
  26. Unger JB, Meeks GR. Vaginal hysterectomy in women with history of previous cesarean delivery. Am J Obstet Gynecol 1998; 179:1473.
  27. Lindquist SAI, Shah N, Overgaard C, et al. Association of Previous Cesarean Delivery With Surgical Complications After a Hysterectomy Later in Life. JAMA Surg 2017.
  28. Agostini A, Bretelle F, Cravello L, et al. Vaginal hysterectomy in nulliparous women without prolapse: a prospective comparative study. BJOG 2003; 110:515.
  29. Isik-Akbay EF, Harmanli OH, Panganamamula UR, et al. Hysterectomy in obese women: a comparison of abdominal and vaginal routes. Obstet Gynecol 2004; 104:710.
  30. Rafii A, Samain E, Levardon M, et al. Vaginal hysterectomy for benign disorders in obese women: a prospective study. BJOG 2005; 112:223.
  31. Rasmussen KL, Neumann G, Ljungström B, et al. The influence of body mass index on the prevalence of complications after vaginal and abdominal hysterectomy. Acta Obstet Gynecol Scand 2004; 83:85.
  32. Heinberg EM, Crawford BL 3rd, Weitzen SH, Bonilla DJ. Total laparoscopic hysterectomy in obese versus nonobese patients. Obstet Gynecol 2004; 103:674.
  33. Cosin JA, Brett Sutherland MA, Westgate CT, Fang H. Complications of Robotic Gynecologic Surgery in the Severely Morbidly Obese. Ann Surg Oncol 2016; 23:4035.
  34. Iavazzo C, Gkegkes ID. Robotic assisted hysterectomy in obese patients: a systematic review. Arch Gynecol Obstet 2016; 293:1169.
  35. Shah DK, Vitonis AF, Missmer SA. Association of body mass index and morbidity after abdominal, vaginal, and laparoscopic hysterectomy. Obstet Gynecol 2015; 125:589.
  36. Dorsey JH, Steinberg EP, Holtz PM. Clinical indications for hysterectomy route: patient characteristics or physician preference? Am J Obstet Gynecol 1995; 173:1452.
  37. Davies A, Vizza E, Bournas N, et al. How to increase the proportion of hysterectomies performed vaginally. Am J Obstet Gynecol 1998; 179:1008.
  38. Kovac SR. Decision-directed hysterectomy: a possible approach to improve medical and economic outcomes. Int J Gynaecol Obstet 2000; 71:159.
  39. Sanei-Moghaddam A, Ma T, Goughnour SL, et al. Changes in Hysterectomy Trends After the Implementation of a Clinical Pathway. Obstet Gynecol 2016; 127:139.
  40. Wallenstein MR, Ananth CV, Kim JH, et al. Effect of surgical volume on outcomes for laparoscopic hysterectomy for benign indications. Obstet Gynecol 2012; 119:709.
  41. Twijnstra AR, Blikkendaal MD, van Zwet EW, et al. Predictors of successful surgical outcome in laparoscopic hysterectomy. Obstet Gynecol 2012; 119:700.
  42. Vree FE, Cohen SL, Chavan N, Einarsson JI. The impact of surgeon volume on perioperative outcomes in hysterectomy. JSLS 2014; 18:174.
  43. Mehta A, Xu T, Hutfless S, et al. Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications. Am J Obstet Gynecol 2017; 216:497.e1.
  44. Chen YJ, Wang PH, Ocampo EJ, et al. Single-port compared with conventional laparoscopic-assisted vaginal hysterectomy: a randomized controlled trial. Obstet Gynecol 2011; 117:906.
  45. Bush AJ, Morris SN, Millham FH, Isaacson KB. Women's preferences for minimally invasive incisions. J Minim Invasive Gynecol 2011; 18:640.
  46. Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev 2012; :CD004993.
  47. Andersen LL, Alling Møller LM, Gimbel HM. Objective comparison of subtotal vs. total abdominal hysterectomy regarding pelvic organ prolapse and urinary incontinence: a randomized controlled trial with 14-year follow-up. Eur J Obstet Gynecol Reprod Biol 2015; 193:40.
  48. ACOG. ACOG Practice Bulletin No. 89. Elective and risk-reducing salpingo-oophorectomy. Obstet Gynecol 2008; 111:231.
  49. Jacoby VL, Vittinghoff E, Nakagawa S, et al. Factors associated with undergoing bilateral salpingo-oophorectomy at the time of hysterectomy for benign conditions. Obstet Gynecol 2009; 113:1259.
  50. Hysterectomy Surveillance --- United States, 1994--1999 http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a1.htm (Accessed on November 25, 2014).
  51. Agostini A, Vejux N, Bretelle F, et al. Value of laparoscopic assistance for vaginal hysterectomy with prophylactic bilateral oophorectomy. Am J Obstet Gynecol 2006; 194:351.
  52. Candiani M, Izzo S, Bulfoni A, et al. Laparoscopic vs vaginal hysterectomy for benign pathology. Am J Obstet Gynecol 2009; 200:368.e1.
  53. Dorsey JH, Holtz PM, Griffiths RI, et al. Costs and charges associated with three alternative techniques of hysterectomy. N Engl J Med 1996; 335:476.
  54. Sculpher M, Manca A, Abbott J, et al. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomised trial. BMJ 2004; 328:134.
  55. Swenson CW, Kamdar NS, Harris JA, et al. Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications. Am J Obstet Gynecol 2016; 215:650.e1.
  56. Falcone T, Paraiso MF, Mascha E. Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy. Am J Obstet Gynecol 1999; 180:955.
  57. Bijen CB, Vermeulen KM, Mourits MJ, de Bock GH. Costs and effects of abdominal versus laparoscopic hysterectomy: systematic review of controlled trials. PLoS One 2009; 4:e7340.
  58. Swenson CW, Kamdar NS, Morgan DM. Comparison of robotic and other minimally-invasive routes of hysterectomy for benign indications. Am J Obstet Gynecol 2016; 214:S458.
  59. Kjerulff KH, Langenberg PW, Rhodes JC, et al. Effectiveness of hysterectomy. Obstet Gynecol 2000; 95:319.
  60. Kjerulff KH, Rhodes JC, Langenberg PW, Harvey LA. Patient satisfaction with results of hysterectomy. Am J Obstet Gynecol 2000; 183:1440.
  61. Roovers JP, van der Bom JG, van der Vaart CH, Heintz AP. Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. BMJ 2003; 327:774.
  62. Rhodes JC, Kjerulff KH, Langenberg PW, Guzinski GM. Hysterectomy and sexual functioning. JAMA 1999; 282:1934.
  63. Aziz A, Brännström M, Bergquist C, Silfverstolpe G. Perimenopausal androgen decline after oophorectomy does not influence sexuality or psychological well-being. Fertil Steril 2005; 83:1021.
  64. Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study: I. Outcomes of hysterectomy. Obstet Gynecol 1994; 83:556.
  65. Brito LG, Pouwels NS, Einarsson JI. Sexual function after hysterectomy and myomectomy. Surg Technol Int 2014; 25:191.
  66. Humalajärvi N, Aukee P, Kairaluoma MV, et al. Quality of life and pelvic floor dysfunction symptoms after hysterectomy with or without pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol 2014; 182:16.
  67. Khastgir G, Studd JW, Catalan J. The psychological outcome of hysterectomy. Gynecol Endocrinol 2000; 14:132.
  68. Farrell SA, Kieser K. Sexuality after hysterectomy. Obstet Gynecol 2000; 95:1045.
  69. Khastgir G, Studd J. Hysterectomy, ovarian failure, and depression. Menopause 1998; 5:113.
  70. MENZER D, MORRIS T, GATES P, et al. Patterns of emotional recovery from hysterectomy; first in a series of reports. Psychosom Med 1957; 19:379.
  71. Farquhar CM, Harvey SA, Yu Y, et al. A prospective study of 3 years of outcomes after hysterectomy with and without oophorectomy. Am J Obstet Gynecol 2006; 194:711.
  72. Halmesmäki K, Hurskainen R, Tiitinen A, et al. A randomized controlled trial of hysterectomy or levonorgestrel-releasing intrauterine system in the treatment of menorrhagia-effect on FSH levels and menopausal symptoms. Hum Reprod 2004; 19:378.
  73. Farquhar CM, Sadler L, Harvey SA, Stewart AW. The association of hysterectomy and menopause: a prospective cohort study. BJOG 2005; 112:956.
  74. Ahn EH, Bai SW, Song CH, et al. Effect of hysterectomy on conserved ovarian function. Yonsei Med J 2002; 43:53.
  75. Moorman PG, Myers ER, Schildkraut JM, et al. Effect of hysterectomy with ovarian preservation on ovarian function. Obstet Gynecol 2011; 118:1271.
  76. Trabuco EC, Moorman PG, Algeciras-Schimnich A, et al. Association of Ovary-Sparing Hysterectomy With Ovarian Reserve. Obstet Gynecol 2016; 127:819.
  77. Spilsbury K, Hammond I, Bulsara M, Semmens JB. Morbidity outcomes of 78,577 hysterectomies for benign reasons over 23 years. BJOG 2008; 115:1473.
  78. Teeluckdharry B, Gilmour D, Flowerdew G. Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta-analysis. Obstet Gynecol 2015; 126:1161.
  79. Mäkinen J, Brummer T, Jalkanen J, et al. Ten years of progress--improved hysterectomy outcomes in Finland 1996-2006: a longitudinal observation study. BMJ Open 2013; 3:e003169.
  80. Gilmour DT, Baskett TF. Disability and litigation from urinary tract injuries at benign gynecologic surgery in Canada. Obstet Gynecol 2005; 105:109.
  81. van der Vaart CH, van der Bom JG, de Leeuw JR, et al. The contribution of hysterectomy to the occurrence of urge and stress urinary incontinence symptoms. BJOG 2002; 109:149.
  82. Brown JS, Sawaya G, Thom DH, Grady D. Hysterectomy and urinary incontinence: a systematic review. Lancet 2000; 356:535.
  83. Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study. Lancet 2007; 370:1494.
  84. de Tayrac R, Chevalier N, Chauveaud-Lambling A, et al. Is vaginal hysterectomy a risk factor for urinary incontinence at long-term follow-up? Eur J Obstet Gynecol Reprod Biol 2007; 130:258.
  85. Thakar R, Ayers S, Clarkson P, et al. Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med 2002; 347:1318.
  86. Miller JJ, Botros SM, Beaumont JL, et al. Impact of hysterectomy on stress urinary incontinence: an identical twin study. Am J Obstet Gynecol 2008; 198:565.e1.
  87. Kudish BI, Shveiky D, Gutman RE, et al. Hysterectomy and urinary incontinence in postmenopausal women. Int Urogynecol J 2014; 25:1523.
  88. Bohlin KS, Ankardal M, Lindkvist H, Milsom I. Factors influencing the incidence and remission of urinary incontinence after hysterectomy. Am J Obstet Gynecol 2017; 216:53.e1.
  89. Christiansen UJ, Hansen MJ, Lauszus FF. Hysterectomy is not associated with de-novo urinary incontinence: A ten-year cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 215:175.
  90. Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol 2008; 198:572.e1.
  91. Aigmueller T, Dungl A, Hinterholzer S, et al. An estimation of the frequency of surgery for posthysterectomy vault prolapse. Int Urogynecol J 2010; 21:299.
  92. ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol 2007; 110:717.
  93. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: Practice Guidelines on the Prevention of Apical Prolapse at the Time of Benign Hysterectomy. J Minim Invasive Gynecol 2014; 21:715.
  94. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997; 89:501.
  95. Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002; 186:1160.
  96. Hendrix SL, Cochrane BB, Nygaard IE, et al. Effects of estrogen with and without progestin on urinary incontinence. JAMA 2005; 293:935.
  97. Dällenbach P, Kaelin-Gambirasio I, Dubuisson JB, Boulvain M. Risk factors for pelvic organ prolapse repair after hysterectomy. Obstet Gynecol 2007; 110:625.
  98. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997; 104:579.
  99. Blandon RE, Bharucha AE, Melton LJ 3rd, et al. Incidence of pelvic floor repair after hysterectomy: A population-based cohort study. Am J Obstet Gynecol 2007; 197:664.e1.
  100. Clark AL, Gregory T, Smith VJ, Edwards R. Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2003; 189:1261.
  101. Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol 2008; 198:572.e1.
  102. Forsgren C, Lundholm C, Johansson AL, et al. Hysterectomy for benign indications and risk of pelvic organ fistula disease. Obstet Gynecol 2009; 114:594.