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Am Fam Physician. 2003;67(6):1340-1343

Hysterectomy is the most common major gynecologic surgery performed in the United States. Concerns about the appropriate use of hysterectomy include neurologic and anatomic disruption of the pelvic region that may lead to adverse effects on bowel, bladder, or sexual function. Subtotal hysterectomy (removal of the uterine fundus, with preservation of the cervix) has been advocated as a less invasive option than total (or “complete”) hysterectomy. Thakar and colleagues present data comparing postoperative pelvic function in patients with subtotal or total hysterectomy.

Women scheduled for hysterectomy at two London hospitals were recruited for the study. After excluding any women with non-benign disease (e.g., suspected cancer, abnormal Papanicolaou smear results, endometriosis, uterine prolapse, or urinary incontinence severe enough to have had medical evaluation), 279 women, most of whom were pre-menopausal, were enrolled. Patients were randomized to receive total or subtotal hysterectomy via an abdominal approach. Eight women did not undergo the assigned surgical procedure because of contravening circumstances (e.g., dense adhesions preventing complete hysterectomy, bleeding cervical stump at subtotal procedure necessitating complete hysterectomy).

Bowel, bladder, and sexual function were assessed at six and 12 months post-procedure. Complete follow-up was unavailable in 32 women (12 percent), and they were not included in the data analysis.

Urinary dysfunction (e.g., stress or urge incontinence, urinary frequency, incomplete emptying) was not significantly different between the two groups after surgery and was slightly improved over preoperative rates in both groups. Urodynamic studies corroborated patient-reported reduction in rates of stress incontinence after surgery. Bowel dysfunction (e.g., constipation, use of laxatives, incontinence of flatus) also showed no significant differences in the two groups postprocedure. Frequency of intercourse, sexual desire, and achievement of orgasm were not significantly affected by surgery in either group. Rates of dyspareunia with deep penetration were similarly decreased after surgery in both groups.

There were, however, differences in complications between the two procedures. Total hysterectomy was associated with a longer hospital stay (approximately one day more) and more bleeding (but no increase in transfusions). Subtotal hysterectomy left 7 percent of women with menstrual bleeding.

The authors conclude that there were no apparent advantages to subtotal hysterectomy compared with total hysterectomy with respect to bowel, bladder, or sexual function, and some women who had the subtotal procedure continued to have menstrual bleeding.

editor’s note: One of the purported advantages to subtotal hysterectomy (with preservation of the cervical stump) is better support of pelvic structures. Strangely enough, the only subjects in this study to experience problems with pelvic relaxation were two patients who had cervical prolapse after subtotal hysterectomy. The one-year postoperative follow-up period is much too short to show whether there may be a difference in pelvic relaxation problems as these mostly premenopausal women advance in age.—b.z.

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