Past, Present, and Future of Hysterectomy

Comparison of different suture techniques for laparoscopic vaginal cuff closure

Laparoscopic hysterectomy is a commonly performed procedure. However, one high-risk complication is vaginal cuff dehiscence. Currently, there is no standardization regarding thread material or suturing technique for vaginal cuff closure. Therefore, this study aimed to compare extracorporeal and intracorporeal suturing techniques for vaginal cuff closure using a pelvic trainer model. Eighteen experts in laparoscopic surgery performed vaginal cuff closures with interrupted sutures using intracorporeal knotting, extracorporeal knotting and continuous, unidirectional barbed sutures. While using an artificial tissue suturing pad in a pelvic trainer, experts performed vaginal cuff closure using each technique according to block randomization. Task completion time, tension resistance, and the number of errors were recorded. After completing the exercises, participants answered a questionnaire concerning the suturing techniques and their performance. Experts completed suturing more quickly (p < 0.001, p < 0.001, respectively) and with improved tension resistance (p < 0.001, p < 0.001) when using barbed suturing compared to intracorporeal and extracorporeal knotting. Furthermore, the intracorporeal knotting technique was performed faster (p = 0.04) and achieved greater tension resistance (p = 0.023) compared to extracorporeal knotting. The number of laparoscopic surgeries performed per year was positively correlated with vaginal cuff closure duration (p = 0.007). Barbed suturing was a time-saving technique with improved tension resistance for vaginal cuff closure.

Beyond Sterilization: A Comprehensive Review on the Safety and Efficacy of Opportunistic Salpingectomy as a Preventative Strategy for Ovarian Cancer

Ovarian cancer (OC) is Canada's third most common gynecological cancer, with an estimated 3000 new cases and 1950 deaths projected in 2022. No effective screening has been found to identify OC, especially the most common subtype, high-grade serous carcinoma (HGSC), at an earlier, curable stage. In patients with hereditary predispositions such as BRCA mutations, the rates of HGSC are significantly elevated, leading to the use of risk-reducing salpingo-oophorectomy as the key preventative intervention. Although surgery has been shown to prevent HGSC in high-risk women, the associated premature menopause has adverse long-term sequelae and mortality due to non-cancer causes. The fact that 75% of HGSCs are sporadic means that most women diagnosed with HGSC will not have had the option to avail of either screening or prevention. Recent research suggests that the fimbrial distal fallopian tube is the most likely origin of HGSC. This has led to the development of a prevention plan for the general population: opportunistic salpingectomy, the removal of both fallopian tubes. This article aims to compile and review the studies evaluating the effect of opportunistic salpingectomy on surgical-related complications, ovarian reserve, cost, and OC incidence when performed along with hysterectomy or instead of tubal ligation in the general population.

Laparoscopic subtotal hysterectomy followed by in-bag transvaginal corpus uteri morcellation and extraction: A case series

OBJECTIVES

Laparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH.

STUDY DESIGN

We report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2 cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients' characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30 days from surgery.

RESULTS

Patients' median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5 min (range 34-143) and uterus weight ranged from 60 g to 470 g (median 210 g). The estimated blood loss was 100 mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2 days (1-3) and no postoperative complications within 30 days from surgery were recorded.

CONCLUSIONS

LSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure.

A Comparative Study of Ultrasound-Guided Quadratus Lumborum Block and Transversus Abdominis Plane Block for Postoperative Analgesia Following Total Abdominal Hysterectomy

BACKGROUND

 Total abdominal hysterectomy (TAH) results in remarkable postoperative pain. Truncal nerve blocks like the quadratus lumborum (QL) block and transversus abdominis plane (TAP) block are described to combat this pain. The aim of the present study was to compare the effectiveness of the QL block with the TAP block in terms of numeric rating scale (NRS) scores as the primary outcome for postoperative pain in TAH. The secondary outcome was time of the first analgesic demand, total analgesic demands required in 24 hr, and patient satisfaction level.

METHODS

 Seventy patients of American Society of Anesthesiologists (ASA) physical status class I and II, aged 35-65 years with a body mass index (BMI) 18-30 kg/m² planned for elective TAH under spinal anaesthesia were randomly allocated into two groups. Group Q received QL block and Group T received TAP block under ultrasound guidance with 40 ml of 0.25% bupivacaine of which 20 ml was injected on either side.

RESULTS

 Demographic data of both groups was comparable. The NRS pain score was significantly lower in Group Q compared to Group T at the fourth and sixth hour. The mean first analgesic demand was significantly early in Group T compared to Group Q (5.69 ± 0.87 hr vs. 11.23 ± 2.22 hr) and total analgesic demands were significantly greater in Group T than Group Q. The mean patient satisfaction score was significantly high in Group Q compared to Group T (5.8 ± 0.41 vs. 4.74 ± 0.44).

CONCLUSION

The combined posterior and anterior approach of the QL block may represent a more efficacious alternative to the TAP block in patients after TAH. Further studies are recommended to evaluate the ideal dose, volume and approach for the QL block.

Self-acceptance Affects Attitudes in Caring for Sexual Function after Hysterectomy

BACKGROUND: A comprehensive understanding of several approaches, both pharmacological and non-pharmacological, is needed to reduce sexual function problems after hysterectomy. As one example, the research of Rawland et al. (2015) and that study found that cognitive, affective, motivational, behavioral, self-efficacy, and sexual acceptance responses could potentially play an important roles in the assessment of appropriate care. However, in general, there is no research that explains that self-acceptance can affect attitudes. AIM: This study aims to analyze the correlation between self-acceptance with attitudes toward caring for sexual function after hysterectomy. METHODS: The data measured were self-acceptance and attitudes toward treatment of sexual function after hysterectomy which was obtained from post-hysterectomy women. Data on self-acceptance using the Self-acceptance – Scale for Persons with Early Blindness (SAS-EB) questionnaire and data on attitudes toward caring for sexual function were made by researchers using references from the theory planned of behavior (TPB) (Alshawish et al., 2020). Statistical analysis used was Chi-square to analyze self-acceptance with attitudes to caring for sexual function after hysterectomy. RESULTS: This study found the importance of self-acceptance in determining attitudes toward caring for sexual function after hysterectomy. A person’s positive attitude will affect behavior to treat sexual function after hysterectomy. CONCLUSION: In general, this study proves that self-acceptance is related to attitudes to caring for sexual function after hysterectomy.

Comparison of morphine and dexmedetomidine as adjuvants to isobaric levobupivacaine for spinal anesthesia in patients undergoing abdominal hysterectomy

Introduction:

Various adjuvants to local anesthetics are used in spinal anesthesia for improving the quality and prolonging postoperative analgesia. We aim to compare the analgesic efficacy of morphine or dexmedetomidine given intrathecally as adjuvants to isobaric levobupivacaine.

Materials and Methods:

Seventy patients of age group 18–60 years, American Society of Anesthesiologists 1 and 2 undergoing elective abdominal hysterectomy, were randomized into two groups. Group M received spinal anesthesia with 3 mL of 0.5% isobaric levobupivacaine with 250 μg of preservative-free morphine. Group D received 3 mL of 0.5% isobaric levobupivacaine with 5 μg of dexmedetomidine. Quality of anesthesia, sensory and motor block characteristics, duration of effective analgesia, and incidence of side effects were compared.

Results:

The time for the first analgesic request was 320.80 ± 41.75 min in the dexmedetomidine group as compared to the morphine group (451.63 ± 38.55 min), P = 0.000. The analgesic requirement in the first 24 h was significantly higher in Group D as compared to Group M, P = 0.000. Adverse effects were similar in both the groups, except pruritus which was seen only in Group M.

Conclusion:

Our study shows that the use of intrathecal morphine as an adjuvant to isobaric levobupivacaine provides better analgesia than intrathecal dexmedetomidine; however, adverse effects such as nausea and pruritus may be seen.

Historical and projected hysterectomy rates in the USA: Implications for future observed cervical cancer rates and evaluating prevention interventions

BACKGROUND

SEER-reported cervical cancer incidence rates reflect the total female population including women no longer at risk due to hysterectomy. Hysterectomy rates have been declining in the United States as alternative treatments have become available, which could result in an apparent increase in SEER-reported cervical cancer rates. We aimed to obtain nationally representative historical data on hysterectomy rates in USA, use trends analysis to project rates back to 1935 and forward to 2035, and then predict the impact of changing hysterectomy rates on SEER-reported cervical cancer rates.

METHODS

We performed a systematic search of Medline, Embase, Premedline, Cochrane Central databases and extracted nationally-representative hysterectomy incidence data from 1965 to 2009, including data on the number of cervix-preserving (subtotal) procedures. We then projected rates back to 1935, and forward to 2035 based on trends from joinpoint regression. These rates were then used to estimate hysterectomy prevalence out to 2035, and then to predict the impact of changing hysterectomy rates on SEER-reported cervical cancer rates to 2035. We examined alternative assumptions regarding projected hysterectomy incidence rates out to 2035, including a scenario in which rates decline no further from 2009 rates, and a scenario where rates decline at twice the baseline rate.

RESULTS

Estimated age-standardized hysterectomy incidence increased from 2.4 to 10.6 per 1000 women between 1935 and 1975. Thereafter, rates are predicted to fall to 3.9 per 1000 by 2035. Subtotal hysterectomy procedures declined from being the predominant method in 1935 to less than 12% of procedures from 1970 onwards. Consequently, holding all else constant, an increase in SEER-reported age-standardized cervical cancer incidence rates (ages 0-85+) of 9% is expected from 2009 to 2035. The predictions were minimally impacted by alternative scenarios for future hysterectomy rates.

CONCLUSIONS

Declining hysterectomy rates have implications for the interpretation of SEER-reported cervical cancer rates. A background increase in cervical cancer rates due to decreasing population hysterectomy exposure may partially offset expected decreases from recent cervical screening changes recommended by the US Preventive Services Task Force. Evaluations of new cervical cancer prevention opportunities should consider the background impact of historical and projected hysterectomy rates.

Use of Paracervical Block Before Laparoscopic Supracervical Hysterectomy

Background and Objective:

Some patients who undergo laparoscopic hysterectomy request overnight admission for pain management, thus increasing costs for a surgery that is safe for same-day discharge. We wanted to evaluate whether a paracervical block of bupivacaine with epinephrine before laparoscopic supracervical hysterectomy would decrease overnight admission rates, postoperative pain, and pain medication requirement

Methods:

This was a randomized, double-blind, placebo-controlled, parallel-group trial (Canadian Task Force classification I) at an academic medical center. Patients undergoing laparoscopic supracervical hysterectomy were randomized to a 20-mL paracervical injection of either 0.25% bupivacaine with epinephrine or 20 mL normal saline before skin incision. All providers, except the circulating nurse, were blinded. The primary outcome was overnight hospital admission rate. Secondary outcomes included postoperative pain medication use and pain scores. Analysis included t test, χ², Wilcoxon, and ANOVA.

Results:

One hundred thirty-two patients were enrolled—68 in the treatment group and 64 in the placebo group. Demographics were similar between groups. The unplanned overnight admission rate was 34% for the treatment group and 27% for the placebo group (P = .25). After discharge, the treatment group used on average 8.5 tablets of narcotics, whereas the placebo group used 11.7 tablets (P = .07). The treatment group took 13.1 tablets of nonnarcotic analgesics compared to 11.2 in the placebo group (P = .57). Both groups reported similar pain scores.

Conclusion:

Paracervical block with bupivacaine and epinephrine before laparoscopic supracervical hysterectomy did not decrease overnight admission rate or affect postoperative pain. Postoperative opiate use was minimally decreased.

[Initial experience in the laparoscopic treatment of benign and malignant gynaecological diseases in the Hospital Regional de Alta Especialidad in Oaxaca]

BACKGROUND

The history of laparoscopic surgery in gynaecological diseases progressed with the advances of Semm, as well as with the development of tools, equipment, and energy that led to its development in all surgical areas, including oncology.

OBJECTIVE

To present the initial experience in the laparoscopic treatment of benign and malignant gynaecological disease in the Hospital Regional de Alta Especialidad in Oaxaca.

MATERIAL AND METHODS

An analysis was performed on a total of 44 cases, distributed into: type III radical hysterectomy for invasive cervical cancer, hysterectomy type I cervical cancer in situ, extrafascial hysterectomy for benign disease, routine endometrium, ovary and routine salpingo-oophorectomy. The variables included age, BMI, surgical time, bleeding, intraoperative and postoperative complications, conversion, hospital stay, and pathology report.

RESULTS

Hysterectomy type III; age 40.2 years, BMI 25.8kg/m², 238ml bleeding, operative time 228min, 2.6-day hospital stay, intraoperative or postoperative complications, tumour size 1.1cm, 14 lymph nodes dissected, vaginal and negative parametrical edge. Type I hysterectomy cervical cancer in situ: 51 years, BMI 23.8kg/m², 80ml bleeding, operative time 127minutes, uterus of 9cm, length of stay of 2 days, a conversion by external iliac artery injury, with bleeding of 1500ml. Routine endometrium: 50.3 years, BMI 30.3kg/m², 83ml bleeding, operative time 180minutes, uterus 12.6cm, length of stay 2.3 days, no complications.

CONCLUSION

The management of benign and malignant pelvic diseases using laparoscopy is feasible and safe, with shorter hospital stays and a prompt recovery to daily activities.

Comparison of the short-term and long-term outcomes of laparoscopic hysterectomies and of abdominal hysterectomies: a case study of 4,895 patients in the Guangxi Zhuang Autonomous Region, China

BACKGROUND

To evaluate the short-term and long-term outcomes after laparoscopic hysterectomy (LH) compared with abdominal hysterectomy (AH) in case of benign gynecological disease.

METHODS

A multi-center cohort retrospective comparative study of population among 4,895 hysterectomies (3,539 LH vs.1,356 AH) between 2007 and 2013 was involved. Operative time (OT), estimated blood loss (EBL), intra-operative and post-operative complications, passing flatus; days with indwelling catheter, questionnaires covering pelvic floor functions and sexual functions were assessed.

RESULTS

The EBL (174.1±157.4 vs. 263.1±183.2 cc, LH and AH groups, respectively), passing flatus (38.7±14.1 vs. 48.1±13.2 hours), days with indwelling catheter (1.5±0.6 vs. 2.2±0.8 days), use of analgesics (6.5% vs. 73.1%), intra-operative complication rate (2.4% vs. 4.1%), post-operative complication rate (2.3% vs. 5.7%), post-operative constipation (12.1% vs. 24.6%), mild and serious stress urinary incontinence (SUI) post-operative (P<0.001; P=0.014), and proportion of Female Sexual Functioning Index (FSFI) total score <26.55 post-operative (P<0.001) of the LH group were significantly less than those of AH group. There were no significant differences in OT (106.5±34.5 vs. 106.2±40.3 min) between the two groups.

CONCLUSIONS

LH is a safe and efficient operation for improving patients?long-term quality of life (QoL), and LH is a cost-effectiveness procedure for treating benign gynecological disease. LH is superior to AH due to reduced EBL, reduced post-operative pain and earlier passing flatus.

The End of the Hysterectomy Epidemic and Endometrial Cancer Incidence: What Are the Unintended Consequences of Declining Hysterectomy Rates?

Population-level cancer incidence rates are one measure to estimate the cancer burden. The goal is to provide information on trends to measure progress against cancer at the population level and identify emerging patterns signifying increased risk for additional research and intervention. Endometrial cancer is the most common of the gynecologic malignancies but capturing the incidence of disease among women at risk (i.e., women with a uterus) is challenging and not routinely published. Decreasing rates of hysterectomy increase the number of women at risk for disease, which should be reflected in the denominator of the incidence rate calculation. Furthermore, hysterectomy rates vary within the United States by multiple factors including geographic location, race, and ethnicity. Changing rates of hysterectomy are important to consider when looking at endometrial cancer trends. By correcting for hysterectomy when calculating incidence rates of cancers of the uterine corpus, many of the disparities that have been assumed for this disease are diminished.

Subtotal versus total abdominal hysterectomy: randomized clinical trial with 14-year questionnaire follow-up

OBJECTIVE

The objective of the study was to compare long-term results of subtotal vs total abdominal hysterectomy for benign uterine diseases 14 years after hysterectomy, with urinary incontinence as the primary outcome measure.

STUDY DESIGN

This was a long-term follow-up of a multicenter, randomized clinical trial without blinding. Eleven gynecological departments in Denmark contributed participants to the trial. Women referred for benign uterine diseases who did not have contraindications to subtotal abdominal hysterectomy were randomized to subtotal (n = 161) vs total (n = 158) abdominal hysterectomy. All women enrolled in the trial from 1996 to 2000 who were still alive and living in Denmark (n = 304) were invited to answer the validated questionnaire used in prior 1 and 5 year follow-ups. Hospital contacts possibly related to hysterectomy from 5 to 14 years postoperatively were registered from discharge summaries from all public hospitals in Denmark. The results were analyzed as intention to treat and per protocol. Possible bias caused by missing data was handled by multiple imputation. The primary outcome was urinary incontinence; the secondary outcomes were pelvic organ prolapse, constipation, pain, sexuality, quality of life (Short Form-36 questionnaire), hospital contacts, and vaginal bleeding.

RESULTS

The questionnaire was answered by 197 of 304 women (64.8%) (subtotal hysterectomy [n = 97] [63.4%]; total hysterectomy [n = 100] [66.2%]). Mean follow-up time was 14 years and mean age at follow-up was 60.1 years. After subtotal abdominal hysterectomy, 32 of 97 women (33%) complained of urinary incontinence compared with 20 of 100 women (20%) after total abdominal hysterectomy 14 years after hysterectomy (relative risk, 1.67; 95% confidence interval, 1.02-2.70; P = .035). After a multiple imputation analysis, this difference disappeared (relative risk, 1.36; 95% confidence interval, 0.86-2.13; P = .19). No differences were seen in any of the secondary outcomes.

CONCLUSION

Subtotal abdominal hysterectomy was not superior to total abdominal hysterectomy on any outcomes. More women seem to have subjective urinary incontinence 14 years after subtotal abdominal hysterectomy. This result was not confirmed by multiple imputation analysis and should be interpreted cautiously.

Absent organs--present selves: exploring embodiment and gender identity in young Norwegian women's accounts of hysterectomy

In this paper, we explore how younger women in Norway construct their embodiment and sense of self after hysterectomy. To do this, we conducted in-depth interviews with eight ethnic Norwegian women aged between 25 and 43 who had undergone hysterectomy. In line with a broad phenomenological approach to illness, the study was designed to explore the trajectories of the women's illness with a specific focus on concrete human experience and identity claims from a subjective point of view. In analysing the stories, we encountered feelings of suffering due to the loss of the uterus as well as profound side-effects, such as menopause. However, we also found evidence of relief from being treated for heavy bleeding and serious illness. In order to accentuate the individual voices in these illness stories, we chose a case-oriented analysis in line with Radley and Chamberlain (2001) and Riessman (2008). From this, two main seemingly contradictory storylines stood out: They have removed what made me a woman versus Without a uterus, I feel more like a woman. We also identified heteronormativity as an unstated issue in both these storylines and in the research data as a whole. Acknowledging diversity in the way women experience hysterectomy is important for a better understanding of the ways in which hysterectomy may affect women as humans as well as for developing more cultural competent healthcare services for this group.

Hysterectomy and its impact on the calculated incidence of cervical cancer and screening coverage in Denmark

BACKGROUND

The incidence rates of cervical cancer and the coverage in cervical cancer screening are usually reported by including in the denominator all women from the general population. However, after hysterectomy women are not at risk anymore of developing cervical cancer. Therefore, it makes sense to determine the indicators also for the true at-risk populations. We described the frequency of total hysterectomy in Denmark and its impact on the calculated incidence of cervical cancer and the screening coverage.

MATERIAL AND METHODS

With data from five Danish population-based registries, the incidence rate of cervical cancer and the screening coverage for women aged 23-64 years on 31 December 2010 were calculated with and without adjustments for hysterectomies undertaken for reasons other than cervical cancer. They were calculated as the number of cases divided by 1) the total number of woman-years from the general population; and 2) the at-risk population after exclusion of post-hysterectomy woman-years. Cases were defined as women with cervical cancer (incidence), or as women screened in the recommended interval, with or without adjustment for hysterectomies (coverage).

RESULTS AND CONCLUSIONS

In 2010, the all-age prevalence of hysterectomy was estimated at 6%, and ≥ 16% at age ≥ 65. This translated into an overall 6% increase in the incidence rate of cervical cancer, from 12.8 (unadjusted) to 13.5 (adjusted) per 100,000 woman-years. The screening coverage increased from 76% (unadjusted) to 79% (adjusted). In Denmark, hysterectomies do not have a large overall impact on the calculated cancer incidence and screening coverage. Nevertheless, at ≥ 65 years adjusted rates would increase by almost 20% compared to unadjusted rates. This suggests that calculating disease risks per organ-years may have a role in understanding the true burden of the disease in a population at risk of developing that disease.

Laparoscopic supracervical hysterectomy (LSH) versus total laparoscopic hysterectomy (TLH): an implementation study in 1,952 patients with an analysis of risk factors for conversion to laparotomy and complications, and of procedure-specific re-operations

PURPOSE

To compare laparoscopic supracervical hysterectomy (LSH) with total laparoscopic hysterectomy (TLH) with regard to relevant surgical parameters and risk factors of conversion to laparotomy and complications.

METHODS

This prospective, open, single-center, interventional study included women with benign gynecologic disease who underwent standardized LSH or TLH. The techniques were compared for conversion rate and mean operating time, hemoglobin drop, hospital stay, and complication rates using descriptive statistics and standard non-parametric statistical tests. Risk factors of conversion and complications were identified by logistic regression analysis.

RESULTS

During January 2003 to December 2010, 1,952 women [mean age (SD): 47.5 (7.2) years] underwent LSH [1,658 (84.9%)] or TLH [294 (15.1%)], mostly (>70%) for uterine fibroids. Significant differences in surgical parameters were observed for conversion rate (LSH/TLH: 2.6/6.5%), mean operating time [87 (34)/103 (36) min], hemoglobin drop [1.3 (0.8)/1.6 (1.0) g/dL], and hospital stay [4.3 (1.5)/4.9 (2.8) days]. Overall intraoperative (0.2/0.7%) and long-term (>6 weeks) post-operative (0.8/1.7%) complication rates did not differ significantly, but the short-term LSH complication rate was significantly lower (0.6 vs. 4.8%). Spotting (LSH, 0.2%) and vaginal cuff dehiscence (TLH, 0.7%) were long-term method-specific complications. Logistic regression showed that uterine weight and extensive adhesiolysis were significant factors for conversion while previous surgery, age, and BMI were not. Major risk factors of short-term complications were age, procedure (LSH/TLH), and extensive adhesions.

CONCLUSIONS

Both procedures proved effective and were well tolerated. LSH performed better than TLH regarding most outcome measures. LSH is associated with very low rates of re-operation and spotting.

When should surgical treatment be considered for premenstrual dysphoric disorder?

Premenstrual mood disorders afflict a substantial number of women of reproductive age. Medical treatments provide excellent symptomatic relief to many women but at times a poor therapeutic response or adverse effects attributable to these therapies lead women to seek alternative solutions. Oophorectomy (with concomitant hysterectomy) followed by low-dose estrogen therapy has been shown to be an effective alternative for such cases of menstrual-cycle-related mood disorder.

Effects of vaginal hysterectomy on anorectal sensorimotor functions--a prospective study

BACKGROUND

While bowel and bladder dysfunction are recognized consequences of a radical hysterectomy, the effects of a simple hysterectomy on anorectal sensorimotor functions, particularly rectal sensation, vary among studies and the effects on rectal compliance remain unknown. Our aims were to prospectively evaluate anorectal sensorimotor functions before and after a hysterectomy.

METHODS

Anal pressures, rectal compliance, capacity, sensation, and bowel symptoms were assessed before, at 2 months, and at 1 year after a simple vaginal hysterectomy for benign indications in 19 patients. Rectal staircase (0-44 mmHg, 4-mmHg steps), ramp (0-200 mL at 50, 200 and 600 mL min(-1)) and phasic distentions (8, 16, and 24 mmHg above operating pressure) were performed.

KEY RESULTS

Anal resting (63 ± 4 before, 56 ± 4 mmHg after) and squeeze pressures (124 ± 12 before, 124 ± 12 mmHg after), rectal compliance and capacity (285 ± 12 before, 290 ± 11 mL 1 year after), and perception of phasic distentions were not different before vs after a hysterectomy. Sensory thresholds for first sensation and the desire to defecate were also not different, but pressure and volume thresholds for urgency were somewhat greater (Hazard ratio = 0.7, 95% CI [0.5, 1.0]) 1 year after (vs before) a hysterectomy. Rectal pressures were higher (P < 0.0001) during fast compared with slow ramp distention; this rate effect was greater at 1 year after a hysterectomy, particularly at 100 mL (P = 0.04).

CONCLUSIONS & INFERENCES

A simple vaginal hysterectomy has relatively modest effects (i.e., somewhat reduced rectal urgency and increased stiffness during rapid distention) on rectal sensorimotor functions.

Hysterectomy improves sexual response? Addressing a crucial omission in the literature

The prevailing view in the literature is that hysterectomy improves the quality of life. This is based on claims that hysterectomy alleviates pain (dyspareunia and abnormal bleeding) and improves sexual response. Because hysterectomy requires cutting the sensory nerves that supply the cervix and uterus, it is surprising that the reports of deleterious effects on sexual response are so limited. However, almost all articles that we encountered report that some of the women in the studies claim that hysterectomy is detrimental to their sexual response. It is likely that the degree to which a woman's sexual response and pleasure are affected by hysterectomy depends not only on which nerves were severed by the surgery, but also the genital regions whose stimulation the woman enjoys for eliciting sexual response. Because clitoral sensation (via pudendal and genitofemoral nerves) should not be affected by hysterectomy, this surgery would not diminish sexual response in women who prefer clitoral stimulation. However, women whose preferred source of stimulation is vaginal or cervical would be more likely to experience a decrement in sensation and consequently sexual response after hysterectomy because the nerves that innervate those organs, that is, the pelvic, hypogastric, and vagus nerves, are more likely to be damaged or severed in the course of hysterectomy. However, all published reports of the effects of hysterectomy on sexual response that we encountered fail to specify the women's preferred sources of genital stimulation. As discussed in the present review, we believe that the critical lack of information as to women's preferred sources of genital stimulation is key to accounting for the discrepancies in the literature as to whether hysterectomy improves or attenuates sexual pleasure.