Total versus Subtotal (Partial or Supracervical)
The uterus is joined at the cervix to the vagina and by the fallopian or uterine tubes to the ovaries.
Hysterectomy is a very common operation. The uterus may be completely removed, partially removed, or may be removed with the tubes and ovaries. A partial (subtotal or supracervical) hysterectomy is removal of just the upper portion of the uterus, leaving the cervix (the neck of the womb) intact. A total hysterectomy is removal of the entire uterus and the cervix .A hysterectomy may be done through an abdominal incision (abdominal hysterectomy) or through a vaginal incision (vaginal hysterectomy).
Most patients recover completely from hysterectomy. Removal of the ovaries causes immediate menopause and hormone replacement therapy may be recommended for young patients .
The average hospital stay is from 4-5 days. Complete recovery may require 2-3 months. Recovery from a vaginal hysterectomy is faster than from a abdominal hysterectomy. A catheter may remain in place for 1-2 days after the operation to help the bladder pass urine. Moving about as soon as possible helps to avoid blood clots in the legs and other problems. Sexual activities should be avoided for 6 to 8 weeks after a hysterectomy.
Total versus Subtotal (Partial or Supracervical) Hysterectomy
Subtotal abdominal hysterectomy has increased in popularity in recent years. It is thought that conservation of the cervix minimizes neurologic and anatomical disruption and that it therefore also helps to minimize potential adverse effects on bladder, bowel, and sexual function. In addition, it is theorized that subtotal abdominal hysterectomy decreases the incidence of posthysterectomy prolapse of the vaginal vault by preserving connective-tissue support of the upper vagina. The following are scientific studies that showed that suggest that subtotal abdominal hysterectomy confers no advantage over total abdominal hysterectomy.
Outcomes after Total versus Subtotal Abdominal Hysterectomy
N Engl J Med. 2002;347:1318-1325.
Background
It is uncertain whether subtotal abdominal
hysterectomy results in
better bladder, bowel, or sexual function than total
abdominal hysterectomy.
Methods We conducted a randomized,
double-blind trial comparing total
and subtotal abdominal
hysterectomy in 279 women referred
for hysterectomy because of
benign disease; most of the women were premenopausal. The main outcomes
were measures of bladder, bowel, and sexual function at 12 months. We
also evaluated postoperative complications.
Results The rates of urinary
frequency (urination more than seven times during the day) were 33
percent in the subtotal-hysterectomy
group and 31 percent in the total-hysterectomy
group before surgery, and they fell to 24 percent and 20 percent,
respectively, at 12 months (P=0.03 for the change over time within
each group; P=0.84 for the interaction between the treatment
assignment and time). The reduction in nocturia and stress
incontinence and the improvement in bladder capacity were similar in
the two groups. The frequency of bowel symptoms (as indicated by
reported constipation and use of laxatives) and measures of sexual
function (including the frequency of intercourse and orgasm and the
rating of the sexual relationship with a partner) did not change
significantly in either group after
surgery. The women in the subtotal-hysterectomy
group had a shorter hospital stay (5.2 days, vs. 6.0 in the total-hysterectomy
group; P=0.04) and a lower rate of fever (6 percent vs. 19 percent,
P<0.001). After subtotal
abdominal hysterectomy,
7 percent of women had cyclical bleeding and 2 percent had cervical prolapse.
Conclusions Neither subtotal
nor total abdominal
hysterectomy adversely
affects pelvic organ function at 12 months. Subtotal
abdominal hysterectomy
results in more rapid recovery and fewer short-term complications but
infrequently causes cyclical bleeding or cervical prolapse.
Bladder Symptoms After Total and Subtotal (Partial or Supracervical) Hysterectomy: Should Gynecologists Recommend a Subtotal Approach?
Epidemiologic studies have suggested an association between hysterectomy and
urinary incontinence. This observation has led to concerns that hysterectomy
might cause urinary symptoms, possibly as a result of the neurologic and
mechanical changes associated with removal of the uterine cervix. Thus, a
logical question is whether supracervical hysterectomy (SCH) might reduce
post-hysterectomy urinary incontinence.
Dr. Holly Richter of the University of Alabama, Birmingham, presented the
results of an important multicenter randomized trial, the Total Or Supracervical
Hysterectomy (TOSH) study. At 4 clinical sites, 135 women with uterine
leiomyomata or abnormal bleeding (refractory to medical management) were
randomized to either SCH or total hysterectomy (TAH). The average age of
participants was 42 years, and 78% were African American. The investigators
compared preoperative data with 2-year post-hysterectomy data. Gynecologists
will be pleased to know that both groups demonstrated significant improvements
in a number of urinary symptoms, including urinary urgency, pelvic pressure,
vaginal bulging, urinary urgency, incomplete voiding, frequency, and nocturia.
More importantly, the women did not worsen with respect to any of the urinary
symptoms investigated. The TAH group demonstrated significant improvement in
symptoms of stress and urge incontinence. (The TOSH trial also examined changes
in sexual function, which will be the subject of an upcoming publication.)
The most important finding of this study was that there were no differences
between the SCH and TAH groups with respect to the postoperative improvements in
urinary symptoms. Women planning hysterectomy for uterine fibroids or abnormal
bleeding should find the results of this study reassuring. These results are
similar to a recent British study of SCH and TAH. That study also demonstrated
improved urinary symptom after both surgeries, with no significant differences
between groups.
A
randomized comparison of total or Subtotal (Partial
or Supracervical)
hysterectomy:
Background To compare surgical
complications and clinical outcomes after
Methods We
conducted a randomized intervention trial in four US clinical centers among 135
Results
Hysterectomy by either technique led to statistically significant
reductions in most symptoms, including pelvic pain or pressure, back pain,
Conclusions We
found
Department of Obstetrics, Gynecology and Reproductive Sciences, University of
California, San Francisco, San Francisco, California, USA
Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy
Jan-Paul W R Roovers, Johanna G van der Bom, C Huub van der Vaart, A Peter M Heintz on behalf
of the Hysterectomy Vaginal versus Abdominal study groupObjectives To compare the effects of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy on sexual wellbeing.
Design Prospective observational study over six months. Setting 13 teaching and non-teaching hospitals in the Netherlands.
Participants 413 women who underwent hysterectomy for benign disease other than symptomatic prolapse of the uterus and endometriosis.
Main outcome measures Reported sexual pleasure, sexual activity, and bothersome sexual problems.
Results Sexual pleasure significantly improved in all patients, independent of the type of hysterectomy. The prevalence of one or more bothersome sexual problems six months after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy was 43% (38/89), 41% (31/76), and 39% (57/145), respectively (2 test, P = 0.88).
Conclusion Sexual pleasure improves after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. The persistence and development of bothersome problems during sexual activity were similar for all three techniques.