- Thomas G Stovall, MD
Thomas G Stovall, MD
- Professor of Obstetrics and Gynecology
- University of Tennessee
- William J Mann, Jr, MD
William J Mann, Jr, MD
- Section Editor — Gynecologic Surgery
- Clinical Professor
- Department of Obstetrics and Gynecology
- Virginia Commonwealth University School of Medicine
Hysterectomy (surgical removal of the uterus) may be performed via an abdominal, vaginal, or laparoscopically-assisted vaginal approach. Once the decision has been made to proceed with hysterectomy, the physician must decide upon the route, which depends upon clinical circumstances and the surgeon's technical expertise. (See "Overview of hysterectomy".)
INDICATIONS AND CONTRAINDICATIONS
The indications for and alternatives to hysterectomy are discussed elsewhere. (See "Overview of hysterectomy".)
Regarding contraindications, in general, gynecologic malignancies should not be approached by a vaginal approach, and prior pelvic radiation is also a relative contraindication.
The reason for the hysterectomy, risks and benefits of the procedure, alternatives, and expectations for outcome, should be discussed with the woman in detail. Few procedures for benign disease engender as much patient anxiety and concern as hysterectomy. There are a number of indications for hysterectomy that are based more upon opinion than evidence from well-designed studies. In these situations, informed consent with thorough exploration of patient preferences and expectations is most important.
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- ACOG Committee on Practice Bulletins. ACOG Practice Bulletin No. 74. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2006; 108:225.
- Kammerer-Doak DN, Rogers RG, Johnson Maybach J, Traynor Mickelson M. Vasopressin as an etiologic factor for infection in gynecologic surgery: a randomized double-blind placebo-controlled trial. Am J Obstet Gynecol 2001; 185:1344.
- Ascher-Walsh CJ, Capes T, Smith J, Michels A. Cervical vasopressin compared with no premedication and blood loss during vaginal hysterectomy: a randomized controlled trial. Obstet Gynecol 2009; 113:313.
- Speer, P, Unger, JB. Does saline really decrease blood loss at vaginal hysterectomy as much as vasopressin. J Pelvic Surg 2001; 7:340.
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- Magos AL, Bournas N, Sinha R, et al. Transvaginal endoscopic oophorectomy. Am J Obstet Gynecol 1995; 172:123.
- Vassallo BJ, Culpepper C, Segal JL, et al. A randomized trial comparing methods of vaginal cuff closure at vaginal hysterectomy and the effect on vaginal length. Am J Obstet Gynecol 2006; 195:1805.
- Chene G, Tardieu AS, Savary D, et al. Anatomical and functional results of McCall culdoplasty in the prevention of enteroceles and vaginal vault prolapse after vaginal hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:1007.
- Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 1999; 180:859.
- Harmanli OH, Khilnani R, Dandolu V, Chatwani AJ. Narrow pubic arch and increased risk of failure for vaginal hysterectomy. Obstet Gynecol 2004; 104:697.
- Nazah I, Robin F, Jais JP, et al. Comparison between bisection/morcellation and myometrial coring for reducing large uteri during vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy: results of a randomized prospective study. Acta Obstet Gynecol Scand 2003; 82:1037.
- Hoffman MS, DeCesare S, Kalter C. Abdominal hysterectomy versus transvaginal morcellation for the removal of enlarged uteri. Am J Obstet Gynecol 1994; 171:309.
- Mazdisnian F, Kurzel RB, Coe S, et al. Vaginal hysterectomy by uterine morcellation: an efficient, non-morbid procedure. Obstet Gynecol 1995; 86:60.
- 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.
- Taylor SM, Romero AA, Kammerer-Doak DN, et al. Abdominal hysterectomy for the enlarged myomatous uterus compared with vaginal hysterectomy with morcellation. Am J Obstet Gynecol 2003; 189:1579.
- Stovall TG, Muneyyirci-Delale O, Summitt RL Jr, Scialli AR. GnRH agonist and iron versus placebo and iron in the anemic patient before surgery for leiomyomas: a randomized controlled trial. Leuprolide Acetate Study Group. Obstet Gynecol 1995; 86:65.
- Doderlein, A, Kronig, S. Die Technik Der Vaginalen Bauchhohlen-Operationen. Verlag Von S Hirzel, Leipzig, 1906.
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- Dunn TS, Shlay J, Forshner D. Are in-dwelling catheters necessary for 24 hours after hysterectomy? Am J Obstet Gynecol 2003; 189:435.
- Alessandri F, Mistrangelo E, Lijoi D, et al. A prospective, randomized trial comparing immediate versus delayed catheter removal following hysterectomy. Acta Obstet Gynecol Scand 2006; 85:716.
- McPherson K, Metcalfe MA, Herbert A, et al. Severe complications of hysterectomy: the VALUE study. BJOG 2004; 111:688.
- Dicker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The Collaborative Review of Sterilization. Am J Obstet Gynecol 1982; 144:841.
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- 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.
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- 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.
- Thakar R, Ayers S, Clarkson P, et al. Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med 2002; 347:1318.
- Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006; 107:1366.
- Ibeanu OA, Chesson RR, Echols KT, et al. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol 2009; 113:6.
- Meeks GR, Harris RL. Surgical approach to hysterectomy: abdominal, laparoscopy-assisted, or vaginal. Clin Obstet Gynecol 1997; 40:886.
- Croak AJ, Gebhart JB, Klingele CJ, et al. Characteristics of patients with vaginal rupture and evisceration. Obstet Gynecol 2004; 103:572.
- Bunker, JP, McPherson, K, Hennenman, PL. Elective hysterectomy. In Bunker JP, Baines BA, Mosteller F (Eds): Costs Risks and Benefits of Surgery. Oxford University Press, New York, 1977.
- Wingo PA, Huezo CM, Rubin GL, et al. The mortality risk associated with hysterectomy. Am J Obstet Gynecol 1985; 152:803.
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- INDICATIONS AND CONTRAINDICATIONS
- PREOPERATIVE PREPARATION
- OPERATIVE PROCEDURE
- Initial steps
- - Entry
- - Ligating the uterine vessels
- Ancillary procedures for complicated cases
- - Uterine morcellation
- - Poor uterine descensus
- - Laparoscopic assistance
- Doderlein procedure
- POSTOPERATIVE CARE AND DISCHARGE INSTRUCTIONS
- Urologic issues
- - Urinary incontinence
- - Ureteral injury
- - Bladder injury
- Bowel injury
- - Small bowel injury
- - Colonic injury
- Urinary retention
- Fallopian tube prolapse
- Vaginal cuff evisceration
- Earlier menopause
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS