Hysterectomy and pelvic organ dysfunction

Unplanned hysterectomy: a comprehensive analysis of race, ethnicity, sociodemographic factors, pregnancy complications, and cardiovascular disease risk factors

OBJECTIVE

To understand the risk of unplanned hysterectomy (UH) in pregnant women better in association with maternal sociodemographic characteristics, cardiovascular disease (CVD) risk factors, and current pregnancy complications.

DESIGN

Using Florida birth data from 2005 to 2014, we investigated the possible interactions between known risk factors of having UH, including maternal sociodemographic characteristics, maternal medical history, and other pregnancy complications. Logistic regression models were constructed. Adjusted odds ratios and 95% confidence intervals were reported.

RESULTS

Several interactions were observed that significantly affected odds of UH. Compared to non-Hispanic White women, Hispanic minority women were more likely to have an UH. The overall risk of UH for women with preterm birth (<37 weeks) and concurrently had premature rupture of membranes (PRoM), uterine rupture, or a previous cesarean delivery was significantly higher than women who delivered to term and had no pregnancy complications. Women who delivered via cesarean who also had preeclampsia, PRoM, or uterine rupture had an overall increased risk of UH. Significantly decreased risk of UH was seen for Black women less than 20 years old, women of other minority races with either less than a high school degree or a college degree or greater, women of other minority races with PRoM, and women with preterm birth and diabetes compared to respective reference groups.

CONCLUSIONS

Maternal race, ethnicity, CVD risk factors, and current pregnancy complications affect the risk of UH in pregnant women through complex interactions that would not be seen in unadjusted models of risk analysis.

Efficacy and patient satisfaction after NovaSure and Minerva endometrial ablation for treating abnormal uterine bleeding: a retrospective comparative study

Objective

Compare amenorrhea rate, menstrual symptoms, patient satisfaction, and adverse events in women who underwent endometrial ablation with the NovaSure versus the Minerva radiofrequency ablation systems.

Methods

We surveyed 189 premenopausal women (mean 40.8±6.2 years old) who underwent endometrial ablation for abnormal uterine bleeding using the NovaSure (n=97) or Minerva (n=92) systems, at four private US gynecology clinics, and whose procedure date was after July 2015 with follow-up ≥3 months. Women were surveyed an average of 11.3±3.9 months (range 137–532 days) after ablation.

Results

The subject-reported amenorrhea rate was 52% higher in NovaSure subjects than Minerva subjects (64% and 42%, respectively; p=0.004). Age and bleeding cyclicity did not affect amenorrhea rate in either group. Normal-to-no bleeding was reported by >90% of subjects after either treatment. NovaSure was significantly more effective than Minerva at reducing pad/tampon use in women with any residual bleeding (2.4±5.2 items/day versus 4.7±5.5 items/day, p=0.049). NovaSure was significantly more effective than Minerva at reducing premenstrual syndrome (PMS) symptoms (p=0.019) and menstrual pain (p=0.003), and more NovaSure subjects (94%) than Minerva subjects (78%) were satisfied with clinical outcomes (p=0.003). Adverse events did not differ by treatment; three women in each group progressed to hysterectomy.

Conclusion

While overall bleeding reduction in premenopausal women with abnormal uterine bleeding was excellent with either endometrial ablation system, NovaSure treatment resulted in a higher patient-reported 1-year amenorrhea rate, and women with residual bleeding used fewer pads and tampons than Minerva-treated women. Additionally, NovaSure subjects reported better menstrual-related life quality and PMS symptom alleviation, and greater satisfaction with outcomes than Minerva-treated women.

Comparison of sexual function between sacrocolpopexy and sacrocervicopexy

Objective

To compare sexual function before and 12 months after between sacrocolpopexy and sacrocervicopexy.

Methods

This retrospective study examined a cohort of 55 sexually active women who underwent either supracervical hysterectomy with sacrocervicopexy (n=28) or total abdominal hysterectomy with sacrocolpopexy (n=27) for stage II to IV pelvic organ prolapse. Pelvic floor support was measured with Pelvic Organ Prolapse-Quantification examination. Pelvic floor function was measured with the Pelvic Floor Distress Inventory-Short Form 20 and sexual function was measured with Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-Short Form 12 (PISQ-12).

Results

Baseline pelvic floor symptoms, demographics and PISQ-12 questionnaire scores were similar between the two groups. Overall improvements in sexual function were seen based on PISQ-12 scores in both groups, but were not statistically significant. No differences were seen in PISQ-12 scores regardless of sparing the cervix or surgical route. Responses to the PISQ-12 question of avoiding sexual intercourse because of vaginal bulging showed significant improvement in both group. No recurrences of prolapse occurred.

Conclusion

In women with pelvic organ prolapse, sexual function after either sacrocolpopexy or sacrocervicopexy was not different. Sexual dysfunction in terms of avoidance of sexual activity because of vaginal bulging was greatly improved in both groups with statistical significance.

Assessment of the impact of urogenital prolapse on sexual dysfunction

Sexual dysfunction is one of the symptoms that motivates women to seek medical help in the management of urogenital prolapse. Conservative or surgical interventions may be offered to treat the prolapse but the question remains as to whether treatment restores sexual function (SF). This article briefly discusses the assessment of SF in women with a urogenital prolapse and reviews the effect of therapeutic interventions on SF.

Prevalence of pelvic floor disorders in women with suspected gynecological malignancy: a survey-based study

INTRODUCTION AND HYPOTHESIS

Understanding of pelvic floor disorders among women with gynecological cancer is limited. The objective of this study was to describe the prevalence of pelvic floor disorders in women with suspected gynecological malignancy before surgery.

METHODS

A cross-sectional study was performed of women aged ≥18 with a suspected gynecological malignancy who enrolled in the University of North Carolina Health Registry/Cancer Survivorship Cohort (HR/CSC) from August 2012 to June 2013. Demographics were obtained from the HR/CSC self-reported data; clinical data were abstracted from the electronic medical record. Subjects completed validated questionnaires (Rotterdam Symptom Checklist and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms) to assess bladder and bowel function.

RESULTS

Among 186 women scheduled for surgery for gynecological malignancy, 152 (82 %) completed baseline assessments before surgery. Mean age was 58.1 ± 13.3 years, and mean BMI was 33.6 ± 8.8 kg/m(2). The majority of subjects had uterine cancer (61.8 %), followed by ovarian (17.1 %) and cervical (11.1 %). At baseline, the rate of urinary incontinence (UI) was 40.9 %. A third of subjects reported stress UI, and one quarter reported urge UI. The overall rate of fecal incontinence was 3.9 %, abdominal pain was 47.4 %, constipation was 37.7 %, and diarrhea was 20.1 %. When comparing cancer types, there were no differences in pelvic floor symptoms.

CONCLUSION

Pelvic floor disorders are common in women with suspected gynecological malignancy at baseline before surgery. Recognizing pelvic floor disorders in the preoperative setting will allow for more individualized, comprehensive care for these women.

Is the Uterus a Sexual Organ? Sexual Function Following Hysterectomy

INTRODUCTION

Hysterectomy has been a mainstay of gynecologic therapy for 100 years. It can be postulated that hysterectomy could affect female sexual function due to psychological factors, and also due to disruption of the local nerve and blood supply and the intimate anatomical relationships of the pelvic organs.

AIM

To evaluate the effects of hysterectomy performed for benign conditions on female sexual function.

METHODS

Peer-reviewed publications were identified through a PubMed search using the search terms "hysterectomy," "benign," "sexual function," "dyspareunia," "orgasm," "libido," and "dysfunction." The search was completed through to February 2015 and was limited to articles published in English.

MAIN OUTCOME MEASURE

The main outcome measure was sexual function after hysterectomy for benign conditions. As hysterectomy is performed via various routes, abdominal (open and laparoscopic) and vaginal, sexual function in each group was evaluated.

RESULTS

Studies were of varying methodology. Majority of women demonstrated either unchanged or improved sexual function after hysterectomy performed by any route in the short term. A significant minority of women reported sexual dysfunction following hysterectomy. Deterioration in sexual function was found on long-term follow-up, which is probably an effect of aging and bilateral salpingo-oophorectomy. There were no proven benefits supracervical compared with total hysterectomy either in the short term (up to 2 years postsurgery) or long term (up to 15 years after hysterectomy).

CONCLUSIONS

Women can be positively reassured that hysterectomy does not negatively affect sexuality. Health professions should be aware that a minority of women may develop adverse effects after the operation. Preoperative education about the potential negative sexual outcomes after surgery may enhance satisfaction with hysterectomy, independent of whether negative sexual outcomes are experienced. Thakar R. Is the uterus a sexual organ? Sexual function following hysterectomy.

Changes in female sexual function after pelvic organ prolapse repair: role of hysterectomy

INTRODUCTION AND HYPOTHESIS

Incontinence and pelvic organ prolapse (POP) have an impact on sexuality. Few studies evaluate the impact of hysterectomy on sexual function. We designed the present observational prospective longitudinal cohort study in order to evaluate the impact of uterus preservation after POP repair on sexual function.

METHODS

Between January 2006 and January 2011, 107 patients with POP, mean age 58 ± 8.9 years, underwent colposacropexy with or without hysterectomy. All the women without uterine disease were offered the chance to preserve the uterus. All patients gave written informed consent and completed the Female Sexual Function Index (FSFI) questionnaire, before and after surgery, provided detailed case history, underwent urogynaecological examination and urodynamic assessment and completed the Urogenital Distress Inventory short form (UDI-6) and Incontinence Impact on Quality of Life short form (IIQ-7) questionnaires, and the satisfaction Visual Analogue Scale (VAS). One year after surgery patients repeated the FSFI questionnaire and underwent a clinical check-up. The primary end-point was post-operative sexual function as evaluated by the FSFI, the secondary end-points were objective anatomical and subjective success, defined respectively as no prolapse and no incontinence-related symptoms.

RESULTS

Sixty-eight patients were included: 32 underwent uterus-sparing surgery and 36 hysterectomy plus colposacropexy. After surgery both groups had significant improvements in the total FSFI score and in the domains of desire, arousal and orgasm. The median post-operative scores of desire, arousal, and orgasm domains showed significant improvements in the uterus-sparing group compared with the hysterectomy group. None of the women had a uterine or vault prolapse recurrence.

CONCLUSIONS

Our data demonstrate that POP plays a role in female sexual dysfunction and uterus sparing surgery is associated with a greater improvement in sexual function.

Total versus subtotal hysterectomy for benign gynaecological conditions

BACKGROUND

Hysterectomy using an abdominal approach removes either the uterus alone (subtotal hysterectomy) or both the uterus and the cervix (total hysterectomy). The latter is more common but the outcomes have not been systematically compared.

OBJECTIVES

To compare short term and long term outcomes of subtotal hysterectomy (STH) with total hysterectomy (TH) for benign gynaecological conditions.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (July 2011), CENTRAL (July 2011), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), CINAHL (January 2005 to July 2011), Biological Abstracts (1980 to December 2005), the National Research Register and relevant citation lists.

SELECTION CRITERIA

Only randomised controlled trials of women undergoing either total or subtotal hysterectomy for benign gynaecological conditions were included.

DATA COLLECTION AND ANALYSIS

Nine trials including 1553 participants were included. Independent selection of trials, assessment for risk of bias and data extraction were undertaken by two review authors and the results compared.

MAIN RESULTS

There was no evidence of a difference in the rates of multiple outcomes that assessed urinary, bowel or sexual function between TH and STH, either in the short term (up to two years post-surgery) or long term (nine years post-surgery). Length of operation (difference of 11 min) and amount of blood lost during surgery (difference of 57 ml) were significantly reduced during subtotal hysterectomy when compared with total hysterectomy. These differences are unlikely to constitute a clinical benefit and there was no evidence of a difference in the odds of blood transfusion. Post-operative fever and urinary retention were less likely (fever: OR 0.48, 95% CI 0.3 to 0.8; retention: OR 0.23, 95% CI 0.1 to 0.8) and ongoing cyclical vaginal bleeding up to two years after surgery was more likely (OR 16.0, 95% CI 6.1 to 41.6) after STH compared with TH. There was no evidence of a difference in the rates of other complications, recovery from surgery, alleviation of pre-surgery symptoms or readmission rates between the two types of hysterectomy carried out through the abdominal or laparoscopic route, although trials comparing the laparoscopic route were underpowered to detect some differences.

AUTHORS' CONCLUSIONS

This review has not confirmed the perception that subtotal hysterectomy offers improved outcomes for sexual, urinary or bowel function when compared with total abdominal hysterectomy. Women are more likely to experience ongoing cyclical bleeding up to a year after surgery with subtotal hysterectomy compared to total hysterectomy.

Outcomes following hysterectomy or endometrial ablation for heavy menstrual bleeding: retrospective analysis of hospital episode statistics in Scotland

OBJECTIVE

To determine the risk of further gynaecological surgery and gynaecological cancer following hysterectomy and endometrial ablation in women with heavy menstrual bleeding.

DESIGN

Population-based retrospective cohort study.

SETTING

Scottish hospitals between 1989 and 2006. Population or sample Scottish women treated with hysterectomy or endometrial ablation for heavy menstrual bleeding between 1989 and 2006.

METHODS

Anonymised data collected by the Scottish Information Services Division were analysed using appropriate methods across the hysterectomy and endometrial ablation groups. Cox proportional hazards regression analysis was used to examine the survival experience for different surgical outcomes after adjustment for age, year of primary operation and Carstairs quintile.

MAIN OUTCOME MEASURES

Further gynaecological surgery and gynaecological cancer in women.

RESULTS

A total of 37,120 women had a hysterectomy, 11,299 women underwent endometrial ablation without a subsequent hysterectomy and 2779 women underwent endometrial ablation followed by a subsequent hysterectomy. The median (interquartile range) duration of follow-up was 11.6 years (7.9, 14.8) and 6.2 years (2.7, 10.8) in the hysterectomy and endometrial ablation (without hysterectomy) cohorts, respectively. Compared with women who underwent hysterectomy, those who underwent ablation were less likely to need pelvic floor repair [adjusted hazards ratio, 0.62; 95% confidence interval (95% CI), 0.50, 0.77] or tension-free vaginal tape surgery for stress urinary incontinence (adjusted hazards ratio, 0.55; 95% CI, 0.41, 0.74). Abdominal hysterectomy was associated with a lower chance than vaginal hysterectomy of pelvic floor repair surgery (hazards ratio, 0.54; 95% CI, 0.45, 0.64). Overall, the number of women diagnosed with cancer was small, the largest group being breast cancer (n = 584, 1.57% and n = 130, 1.15% in the hysterectomy and endometrial ablation groups respectively; adjusted hazards ratio, 1.14; 95% CI, 0.93-1.39).

CONCLUSIONS

Hysterectomy is associated with a higher risk than endometrial ablation of surgery for pelvic floor repair and stress urinary incontinence. Surgery for pelvic floor prolapse is more common after vaginal than abdominal hysterectomy.

Subtotal hysterectomy and myomectomy - vaginally

Vaginal subtotal (or supracervical) hysterectomy and vaginal myomectomy are elegant procedures rarely carried out by the average gynaecologist. Both techniques, however, are easily learned, and in view of the proven advantages of vaginal surgery over abdominal or laparoscopic approaches, they are worthy of a wider application. Subtotal hysterectomy may be preferred to excision of the entire uterus in certain circumstances, and may be carried out vaginally. Vaginal myomectomy allows for a more thorough myomectomy and stronger uterine repair than a laparoscopic procedure, as well as avoiding abdominal wounds. It may represent the optimal approach where fibroids are favourably sited. We first set out the case for subtotal hysterectomy and then describe the development of vaginal subtotal hysterectomy and vaginal myomectomy. We discuss the evidence supporting their use and indications, and then describe techniques for both vaginal procedures.

Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy

OBJECTIVE

We sought to determine whether emergent cesarean supracervical hysterectomy is associated with reduced risk of complications compared to total hysterectomy.

STUDY DESIGN

We conducted a cohort study of 150 women who underwent emergent cesarean hysterectomy at our medical center from 1991 through 2008. We compared the risk factors and indications, and intraoperative and postoperative complications associated with the 2 surgical procedures.

RESULTS

During the study period, a total of 164 cesarean hysterectomies were performed; 91% (n = 150) of these cases were performed emergently of which 53.3% were total and 46.7% were supracervical. There was a significant decline in the relative frequency of total hysterectomy: 71%, 56%, and 24% during 1991-1996, 1997-2002, and 2003-2008, respectively (P < .001). Risk factors, indications for surgery, operative variables, and postoperative complication rates were independent of the type of hysterectomy.

CONCLUSION

Using a cohort of 150 cases from our institution, we found no evidence of increased surgical time or complications associated with total hysterectomy.

Reproductive factors associated with nocturia and urinary urgency in women: a population-based study in Finland

OBJECTIVE

The objective of this study was to evaluate the association of nocturia and urinary urgency with reproductive factors, including parity, the postpartum period, the menopause, hormone replacement therapy, hysterectomy, and surgery for stress urinary incontinence (SUI).

STUDY DESIGN

In 2003-2004, questionnaires eliciting urinary symptoms, reproductive factors, SUI surgery, and potential confounders were mailed to 3000 randomly selected women aged 18-79 years, identified from the Finnish Population Register. Nocturia was defined as 2 or more voids/night. Sudden compelling desire to urinate often or always (scale of never, rarely, often, always) was regarded as urgency. Pregnant and puerperal (6 weeks after delivery) women and those reporting urinary tract infection were excluded.

RESULTS

Responses totaled 2002 (67%). Parity, postpartum (defined as six weeks to one year after delivery) and postmenopausal periods were associated with increased nocturia and SUI surgery with increased urgency (adjusted for age, comorbidity, medication, anthropometric, sociodemographic and lifestyle factors). Hormone therapy and hysterectomy were associated with neither symptom.

CONCLUSION

Reproductive factors associated with nocturia differed from those related to urgency.

Does hysterectomy affect ovarian function? Histopathologic evaluation and serum FSH, inhibin A, and inhibin B levels in an experimental rat model

OBJECTIVE

To evaluate the effects of hysterectomy with ovarian conservation on ovarian histology, and FSH, inhibin A, and inhibin B plasma levels.

STUDY DESIGN

Forty-five female Wistar albino rats were used in this study and randomly divided into two groups: hysterectomy (n=30) and sham-operated (n=15). Blood samples were collected before and after (50 and 100 days) abdominal hysterectomy from both groups to measure plasma levels of FSH, inhibin A, and inhibin B. All animals were sacrificed by decapitation to obtain ovaries for histological examination. For statistical analyses, Mann-Whitney U, Chi-square, Wilcoxon matched pairs signed rank sum tests, and two-sided variance analysis were used and statistical significance was defined as p<0.05.

RESULTS

There was no difference in hormonal variables between groups when the time interval was considered completely [p>0.05 (for FSH p=0.962; for inhibin A p=0.321; for inhibin B p=0.476)]. In the hysterectomy group, the inhibin B level at postoperative day 50 was significantly lower than the control group (p=0.007) and at postoperative day 100, inhibin A concentrations were increased significantly when compared with the levels at both baseline and postoperative day 50 (p<0.001). Histopathologic evaluation of ovaries 100 days after hysterectomy showed that ovaries from the hysterectomy group had significantly fewer primary (p=0.01), preantral (p<0.001), and antral follicles (p<0.001), and significantly more corpora lutea (p<0.001), atretic (p=0.02), and cystic follicles (p=0.003).

CONCLUSION

The results of this experimental rat model suggest that hysterectomy may affect ovarian function.

Pelvic organ prolapse surgery following hysterectomy on benign indications

OBJECTIVE

The objective of the study was to determine the risk for pelvic organ prolapse surgery attributed to hysterectomy on benign indications

STUDY DESIGN

In a nationwide longitudinal study, 162,488 women with hysterectomy from 1973 through 2003 were matched to 470,519 population-based control women. Hazard ratios (HR) with 95% confidence interval (CI) were calculated using Cox regression analyses.

RESULTS

In all, 3.2% (n = 5270) of women with hysterectomy had pelvic organ prolapse surgery, compared with 2.0% (n = 9437) in nonhysterectomized controls. Compared with nonhysterectomized controls, the overall HR for prolapse surgery was 1.7 (95% CI, 1.6 to 1.7) with the highest risks observed in women having had a vaginal hysterectomy (HR 3.8; 95% CI, 3.1 to 4.8). Compared with hysterectomized women with no vaginal births, the HR for prolapse surgery was 2.0 (95% CI, 0.9 to 4.1) among women with 1 vaginal childbirth and 11.3 (95 % CI, 6.0. to 21.1) among women with at least 4 vaginal births.

CONCLUSION

Hysterectomy is associated with an increased risk for subsequent pelvic organ prolapse surgery with multiparous women at particular risk.

Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study

BACKGROUND

Hysterectomy for benign indications has been associated with an increased risk for lower-urinary-tract sequela, but results have been inconclusive. We aimed to establish the risk for stress-urinary-incontinence surgery after hysterectomy for benign indications.

METHODS

We did a nationwide, population-based, cohort study from 1973 to 2003 in Sweden. We identified our population from the Swedish Inpatient Registry. We selected 165 260 women who had undergone hysterectomy (exposed cohort) and a control group of 479 506 individuals who had not had this procedure (unexposed cohort), matched by year of birth and county of residence. In both cohorts, occurrence of stress-urinary-incontinence surgery was established from the Swedish Inpatient Registry. Hazard ratios with 95% CIs were calculated by Cox's proportional-hazards regression.

FINDINGS

During the 30-year observational period, the rate of stress-urinary-incontinence surgery per 100,000 person-years was 179 (95% CI 173-186) in the exposed cohort versus 76 (73-79) in the unexposed cohort. Correspondingly, individuals in the exposed cohort were at increased risk for stress-urinary-incontinence surgery compared with those in the unexposed cohort (hazard ratio 2.4; 95% CI 2.3-2.5), irrespective of surgical technique. Risk for stress-urinary-incontinence surgery varied slightly with time of follow-up: the highest overall risk was recorded within 5 years of surgery (2.7; 2.5-2.9) and the lowest risk was seen after an observation period of 10 years or more (2.1, 1.9-2.2).

INTERPRETATION

Hysterectomy for benign indications, irrespective of surgical technique, increases the risk for subsequent stress-urinary-incontinence surgery. Women should be counselled on associated risks related to hysterectomy, and other treatment options should be considered before surgery.

Pelvic organ function in randomized patients undergoing laparoscopic or abdominal hysterectomy

STUDY OBJECTIVE

To assess the incidence of urinary incontinence, bowel dysfunction, and sexual problems after laparoscopic hysterectomy as compared with abdominal hysterectomy.

DESIGN

Randomized controlled trial (Canadian Task Force classification I).

SETTING

Single-center teaching hospital in the Netherlands, experienced in gynecologic minimal access surgery.

PATIENTS

Women with a benign or malignant condition scheduled for hysterectomy where vaginal hysterectomy was not feasible and laparoscopic hysterectomy was possible.

INTERVENTIONS

Laparoscopic (n = 38) and abdominal hysterectomy (n = 38).

MEASUREMENTS AND MAIN RESULTS

Patients were asked before and 3 months after surgery whether they experienced urinary incontinence and completed the validated questionnaires Urogenital Distress Inventory, Incontinence Impact Questionnaire, Defecatory Distress Inventory, and the Questionnaire for screening Sexual Dysfunctions 1 year after surgery. The incidence of urinary incontinence at 3 months after surgery decreased equally in both groups as compared with baseline. De novo urinary incontinence and sexual problems were rare. One year after surgery, a significant treatment effect favoring laparoscopic hysterectomy was found in the Urogenital Distress Inventory and Incontinence Impact Questionnaire, whereas no differences were found in the Defecatory Distress Inventory and Questionnaire for screening Sexual Dysfunctions.

CONCLUSION

Laparoscopic hysterectomy is superior to abdominal hysterectomy with respect to postoperative symptoms of urinary dysfunction.

Female sexual dysfunction in urogenital prolapse surgery: colposacropexy vs. hysterocolposacropexy

INTRODUCTION

Colposacropexy (CSP), with or without hysterectomy, is a valid technique for the repair of severe urogenital prolapse. For many years, uterine prolapse has represented an indication for hysterectomy, apart from the presence or absence of uterine disease and the patient's desires. Nevertheless, sparing the uterus is essential to women not only to have normal sexual functioning but to maintain physical and anatomical integrity as well.

AIM

To assess sexual function in a group of patients who underwent CSP or hysterocolposacropexy (HSP).

MATERIALS AND METHODS

We enrolled 37 patients who underwent surgery for urogenital prolapse (15 HSP, mean age 53 years; 22 CSP, mean age 56 years). Based on a preliminary sexual history and sexual questionnaire, all patients were sexually active before surgery. At a mean follow-up of 39 months, we reassessed the patients using the Female Sexual Function Index (FSFI).

MAIN OUTCOME MEASURE

We considered sexual activity with a score of 30 = good, 23-29 = intermediate, and <23 = poor.

RESULTS

In patients who underwent CSP and HSP, sexual activity was good in 13% and 26%, intermediate in 33% and 21%, and poor in 54% and 53%, respectively; considering also five patients who no longer had sexual activity postoperatively. Nevertheless, the statistical analysis, performed based on the data obtained from the FSFI questionnaire, showed that there were no significant differences between the two groups of points in terms of total score-CSP 21.1 (1.2-33.5) vs. HSP 22.8 (3.6-34.5)-and single domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) (P = not significant).

CONCLUSIONS

Our data demonstrated no substantial differences regarding sexual activity in patients in which the uterus has been spared as opposed to those in whom it has been removed. Furthermore, in a small percentage of cases, surgery actually reduced regular sexual activity.

Total versus subtotal hysterectomy for benign gynaecological conditions

BACKGROUND

Hysterectomy using an abdominal approach removes either the uterus alone (subtotal hysterectomy) or both the uterus and the cervix (total hysterectomy). The latter is more common but outcomes have not been systematically compared.

OBJECTIVES

To assess and compare outcomes with subtotal hysterectomy versus total abdominal hysterectomy for benign gynaecological conditions.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of controlled trials (December 2005), Central (December 2005), Medline (1966 to December 2005), EmBase (1980 to December 2005), Biological Abstracts (1980 to December 2005), the National Research Register and relevant citation lists.

SELECTION CRITERIA

Only randomised controlled trials of women undergoing either total or subtotal hysterectomy for benign gynaecological conditions were included.

DATA COLLECTION AND ANALYSIS

Three trials that included 733 participants were included. Independent selection of trials and data extraction were undertaken by 2 reviewers and results compared.

MAIN RESULTS

There was no evidence of a difference in the rates of incontinence, constipation or measures of sexual function. In one unblinded trial, a significantly greater proportion of women indicated that they had frequent episodes of urinary incontinence after subtotal hysterectomy when compared with total hysterectomy (OR=2.1, 1.02 to 4.3), but these results were not confirmed by the other two trials that measured both stress and urge incontinence and urinary frequency. . Length of surgery and amount of blood lost during surgery were significantly reduced during subtotal hysterectomy when compared with total hysterectomy, but there was no evidence of a difference in the odds of transfusion. Febrile morbidity was less likely (OR=0.43, 0.25 to 0.75) and ongoing cyclical vaginal bleeding one year after surgery was more likely (OR=11.3, 4.1 to 31.2) after subtotal when compared with total hysterectomy. There was no evidence of a difference in the rates of other complications, recovery from surgery or readmission rates.

AUTHORS' CONCLUSIONS

This review has not confirmed the perception that subtotal hysterectomy offers improved outcomes for sexual, urinary or bowel function when compared with total abdominal hysterectomy. Surgery is shorter and intraoperative blood loss and fever are reduced but women are more likely to experience ongoing cyclical bleeding up to a year after surgery with subtotal hysterectomy compared to total hysterectomy.