Total vs Subtotal Hysterectomy

Transcription

1 Total vs Subtotal Hysterectomy AN UNSOLVED PROBLEM? G Centini, E Zupi, A Wattiez

2 153 patient with 15 years of follow-up

3 The Timeline The first successful hysterectomy (Subtotal)! First Laparoscopic Hysterectomy! Harry Reich! Walter Burnham! From 1840 to 1940 subtotal hysterectomy was the standard procedure! From the 90 s till now we are debating the possible advantages of SH Pap Smear to 1960 debate on cervix removal to avoid cervical cancer! The first documented hysterectomy world wide. (Subtotal)! Charles Clay!! The patient died from massive hemorrhage The first successful total hysterectomy!! Richardson! First Laparoscopic Subtotal Hysterectomy! Semm

4 RCT Anatomy vs

5 The Cochrane Library 2012, Issue 4 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

6 JMIG, 2014 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) No evidence that SH is protective against future POP

7 184 Patients with a mean follow up of 10 years Mean Age: 46 at baseline; 57 at follow up 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.

8 JMIG, 2011 Prospective cohort study of 122 patients, follow-up 1 month

9 De Lancey 2004 Pelvic Organs Suspension Level I: Uterosacral Ligament, Upper part of the paracervix Level II: Pubocervical Fascia, Rectovaginal Fascia Level III: Perineal membrane, levator ani

10 De Lancey 2004 Pelvic Organs Suspension Defects of Level I: Apical prolapse, the cervix or the cuff can move downward

11 The USL plays an important role in pelvic organs support

12 Vaginal Innervation

13 Uterus and vaginal apex innervation

14

15 Bladder Innervation Parasympathetic Sympathetic

16 Contraindication 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

17 Contraindication for Subtotal Hysterectomy The retrocervical localization is very frequent and is better to remove the cervix than leave disease

18 Indication for Subtotal Hysterectomy Performing a colposacropexy Subtotal Hysterectomy is associated with reduced rate of complication

19 Morcellation Courtesy of Prof. Charles Miller

20 Conclusions Subtotal Hysterectomy should be included in the decisional process while counseling the patient The patient has to be informed about the risk of cyclic bleeding and cervical screening Subtotal Hysterectomy should not be performed in case of Endometriosis or Prolapse Subtotal Hysterectomy should be performed if a colposacropexy is scheduled

21 Grazie per l attenzione!!