Open Access

A critical review of laparoscopic total hysterectomy versus laparoscopic supracervical hysterectomy

Gynecological SurgeryEndoscopic Imaging and Allied Techniques20108:629

https://doi.org/10.1007/s10397-010-0629-5

Received: 23 August 2010

Accepted: 8 September 2010

Published: 5 October 2010

Abstract

The purpose of our review is to evaluate the perioperative characteristics of laparoscopic total hysterectomy (LTH) and laparoscopic supracervical hysterectomy (LASH) including the hospital stay, hemoglobin concentration, the operative time, postoperative analgesia, intra and postoperative complications. We also examine the quality of life examining general health, sexual satisfaction, dyspareunia and time to first intercourse

Keywords

Laparoscopic total hysterectomy Laparoscopic supracervical hysterectomy

Introduction

Hysterectomy is the most common gynecological procedure. It is estimated that the rate of hysterectomy is 346 per 100,000 women in Canada and 550 per 100,000 women in the United States [1, 2].These rates are over twofolds of that in Britain, Sweden, the Netherlands and Norway [3]. There are different types of hysterectomy. The most common is abdominal hysterectomy comprising 66% of all hysterectomies followed by the vaginal hysterectomy [4]. Since early nineties, laparoscopic hysterectomy has gained popularity due to its known advantages including short hospital stay, minimal wound related complications and rapid recovery.

Laparoscopic hysterectomy could be divided into laparoscopic assisted vaginal hysterectomy (LAVH), laparoscopic total hysterectomy (LTH) and laparoscopic supracervical hysterectomy (LASH). The proponents of LASH believe that preserving the cervix plays an important role in sexual function, it maintains the pelvic floor support and prevents denervation of bladder and bowel [57]. Others feel that there is no strong evidence to support those claims [810].

The purpose of our review is to evaluate the perioperative characteristics of LTH and LASH including the hospital stay, hemoglobin concentration, the operative time, postoperative analgesia, intra and postoperative complications. We also examine the quality of life examining general health, sexual satisfaction, dyspareunia and time to first intercourse.

Source of data

We performed a literature search using the keywords “hysterectomy, laparoscopic hysterectomy, total hysterectomy, supracervical hysterectomy and subtotal hysterectomy” and conducted the search in the Medline, OVID, EMBASE and the Cochrane of Database of systematic reviews published between 1990 and 2010. We found two prospective trials, four retrospective analyses, and two quality-of-life analysis (Table 1). The only randomized study was published in Italian language and we could only evaluate its abstract. Table 2 shows the demography of patients who underwent LTH or LASH.
Table 1

Studies comparing laparoscopic total hysterectomy (LTH) and laparoscopic supracervical hysterectomy (LASH)

Authors

Design

Number of patients

Author’s conclusion

Morelli et al. 2007 [25]

Randomized trial

71 LASH

No statistically significant difference in surgical complications and clinical outcomes

70 LTH

Harmanli et al. 2009 [11]

Retrospective

566 LASH

Similar overall short-term morbidity

450 LTH

Small statistically significant increase risk of urinary tract injury with LTH

Mueller et al. 2009 [12]

Prospective

118 LASH

LTH is comparable to LASH

113 LTH

Complication rates might be lower with LASH

Van Evert et al. 2010 [16]

Retrospective

192 LASH

LASH is associated with higher long term complications, while LTH is associated with higher short term complications

198 LTH

Mousa et al. 2009 [13]

Retrospective

122 LASH

LTH is associated with longer operating time, but requires less postoperative analgesia than LASH

105 LTH

Cipullo et al. 2009 [14]

Retrospective

157 LASH

LSH is a valid alternative to LTH

157 LTH

Major complications in LASH are significantly less than those in LTH

Kafy et al. 2009 [17]

Retrospective

40 LASH

Both procedures result in similar improvement of general health, body image, sexual function, gastrointestinal and genitourinary functions

40 LTH

Nam et al. 2008 [18]

Prospective

39 LASH

No significant change in quality of sexual life after either procedure

51 LTH

Table 2

Demography of patients who underwent laparoscopic total hysterectomy (LTH) or laparoscopic supracervical hysterectomy (LASH)

 

Type of procedure

Age (years)

Parity

BMI

Uterine weight (g)

Harmanli et al. 2009 [11]

LASH

43.8 ± 5.9

1.85 ± 1.2

28.5 ± 6.9

190.4 ± 170

LTH

44.6 ± 7.9

1.92 ± 1.3

27.9 ± 6.6

218.7 ± 196.2

P value

NS

NS

NS

0.007

Mueller et al. 2009 [12]

LASH

46.7 ± 7.0

NA

25.3 ± 5.1

286.2 ± 209.3

LTH

46.3 ± 7.5

25.4 ± 4.0

264.8 ± 133.6

P value

NS

NS

NS

Van Evert et al. 2010 [16]

LASH

44 (28–60)

NA

NA

NA

LTH

49 (30–81)

Mousa et al. 2009 [13]

LASH

45.7 ± 0.6

1.6 ± 0.1

26.6 ± 0.4

181 ± 12.0

LTH

45.9 ± 0.7

1.7 ± 0.1

26.8 ± 1.5

161 ± 11.6

P value

NA

NA

NA

NS

Cipullo et al. 2009 [14]

LASH

49.5 ± 7.4

NA

27.6 ± 3.5

162.7 ± 112.7

LTH

50.2 ± 7.8

27.6 ± 4.4

169.7 ± 116.6

P value

NS

NS

NS

Kafy et al. 2009 [17]

LASH

46.1 ± 7.0

NA

NA

NA

LTH

46.6 ± 5.3

P value

NA

Nam et al. 2008 [18]

LASH

41.9 ± 4.7

1.8 ± 0.7

22.5 ± 2.4

NA

LTH

46.3 ± 3.7

1.9 ± 0.7

22.8 ± 3.2

P value

NS

NS

NS

Operating time, hospital stay and blood loss

Table 3 shows the operating time, hospital stay and hemoglobin (Hgb) concentration in women who underwent LASH or LTH.
Table 3

Perioperative characteristics of patients who underwent laparoscopic total hysterectomy (LTH) or laparoscopic supracervical hysterectomy (LASH)

 

Harmanli et al. 2009 [11]

Mueller et al. 2009 [12]

Mousa et al. 2009 [13]

Cipullo et al. 2009 [14]

Operating time (min)

LTH 168 ± 61

LTH 114 ± 33.8

LTH 136 ± 3.6

LTH 121.7 ± 44.3

LASH 166 ± 62

LASH 116.5 ± 40

LASH 111 ± 2.9

LASH 111.4 ± 39.1

NS

NS

P < 0.001

P < 0.05

Hospital stay (day)

LTH 1.4 ± 0.7a

LTH 5.7 ± 1.1

LTH 1.5 ± 0.7

NA

LASH 1.2 ± 0.6

LASH 5.3 ± 1.6

LASH 1.8 ± 0.2

P < 001

NS

NS

Postoperative Hgb difference (g/dl)

LTH 1.9 ± 1.0

LTH 1.6 ± 1.1

LTH 2.1

LTH 2.4 ± 0.9

LASH 1.9 ± 0.9

LASH 1.5 ± 1.4

LASH 1.9

LASH 2.1 ± 0.9

NS

NS

NS

P < 0.01

Postoperative analgesia

NA

Ibuprofen (g)

Morphine (mg)

NA

LTH 3.1 ± 0.8

LTH 28 ± 2.9

LASH 2.9 ± 0.8

LASH 37.5 ± 3.4

NS

P < 0.05

NA not available

aRecalculated to days

Operating time

Two of the reviewed studies showed no difference in the operating time between LASH and LTH [11, 12]. Perhaps, the time used for suturing of the vaginal opening compensated that for morcellation. However, Mousa et al. [13] and Cipullo et al. found that LTH was longer than LASH (Table 3). The discrepancy between the studies is unclear. In our practice, we often encounter uterus that is too large to be delivered vaginally forcing us to first partially morcellate the uterus. The time spent to morcellate the uterus adds to the operating time of LTH. We also found that coagulating and cutting with the same instrument make surgery faster. Clearly, there are many factors that can impact the operating time.

Milad et al. [15] compared the operating time of LASH and LAVH and found that LASH was significantly shorter than LAVH. This could be due to the time used to switch from laparoscopy to the vaginal part of the procedure.

Hospital stay and blood loss

The duration of hospital stay of LASH and LTH is comparable. In one study, the authors found that the hospital stay after LTH was about 5 h longer than LASH [11]. It is statistically different, but clinically does not make much difference.

Estimation of blood loss by laparoscopy is usually difficult and not accurate. Using Hgb level as an index of blood loss, three of four studies showed that there was no difference in the decrease in Hgb level after LASH or after LTH [1113]. In contrast, Cipullo et al. [14] reported that LTH might be associated more blood loss than LASH. The reason is not clear.

Postoperative pain

Postoperative analgesia requirement after the two types of laparoscopic hysterectomy was evaluated in two studies [12, 13]. Mueller et al. [12] found no difference in ibuprofen requirement after LTH and after LASH. Although the study was prospective, it appears that the length of uterine incisions and the surgical technique of the surgeons were not standardized. In contrast, Mousa et al. found that the requirement of postoperative analgesia in LTH patients was lower than that in LASH patients [18]. This could be due to a larger incision (≥15 mm) required for the morcellator among women underwent LASH (Table 1).

Postoperative complication

Table 4 shows complications related to hysterectomy including urinary tract injury, cervical stump complication, conversion to laparotomy, reoperation, thromboembolic events, blood transfusion and fever.
Table 4

Intra- and postoperative characteristics of patients who underwent laparoscopic total hysterectomy (LTH) or laparoscopic supracervical hysterectomy (LASH)

Total

Harmanli et al. 2009 [11]

Mueller et al. 2009 [12]

Van Evert et al. 2010 [16]

Mousa et al. 2009 [13]

Cipullo et al. 2009 [14]

LTH 450 n (%)

LASH 566 n (%)

LTH 113 n (%)

LASH 118 n (%)

LTH 198 n (%)

LASH 192 n (%)

LTH 105 n (%)

LASH 122 n (%)

LTH 157 n (%)

LASH 157 n (%)

OR (95% CI)a

Thromboembolic event

1 (0.2)

0

NA

NA

NA

NA

0

1 (0.8)

0

1 (0.6)

Ureter injury

NA

NA

1 (0.9)

0

0

1 (0.5)

1 (1.0)

0

1 (0.6)

0

Bladder injury

10 (2.2)b

3 (0.5)b

NA

NA

NA

NA

1 (1.0)

2 (1.6)

2 (1.2)

0

4.75 (1.21–18.56)b

Blood transfusion

8 (1.8)

9 (1.6)

NA

NA

NA

NA

1 (1.0)

5 (4.1)

1 (0.6)

0

Reoperation

4 (0.9)

1 (0.2)

NA

NA

NA

NA

0

5 (4.1)

2 (1.2)

0

NS

Laparotomy conversion

26 (5.8)

23 (4.1)

0

0

3 (1.5)

9 (5)

0

1 (1.0)

NA

NA

2.25 (1.20–4.22)

NS

Urinary incontinence

NA

NA

NA

NA

2 (1)

2 (1)

0

3 (2.5)

NA

NA

Vaginal bleeding

NA

NA

NA

NA

0

12 (6)

0

1 (0.8)

1 (0.6)

0

Fever

6 (1.3)

5 (0.9)

NA

NA

2 (1)

1 (0.5)

4 (3.8)

2 (1.6)

6 (3.7)

7 (4.4)

NA not available, NS not significant

aOR odds ratio, CI confidence interval

bIncludes both bladder and ureteric injuries

Ureter and bladder injury

The incidence of bladder injury was 1.2–2% with TLH and 0–0.2% with LASH [11, 14].This could be related to more extensive separation of the bladder from the cervix in LTH. Yet, in one study the authors found similar incidence of bladder injury with the two hysterectomy techniques [13]. The incidence of ureter injury is comparable between the two techniques.

Cervical Stump complications and reoperation

One of the drawbacks of supracervical hysterectomy is the occurrence of cyclic bleeding from the cervical stump. For example, Van Evert et al. [16] described 6% incidence of vaginal bleeding in the LASH group, and about one-third of those patients needed subsequent surgical intervention. We previously reported that 4.1% of women after LASH required trachelectomy, mostly due to annoying cyclic vaginal bleeding [13]. This was despite coagulation of the endocervix at the completion of the procedure.

Conversion to laparotomy and other complications

Conversion to laparotomy from LASH or TLH appears to be comparable (Table 3). This is mostly related to technical difficulties, the presence of extensive adhesions and uncontrolled bleeding [11, 16]. The incidence of blood transfusion, thromboembolic events, urinary incontinence and febrile morbidity are also similar.

Quality of life

Table 5 demonstrates the quality of life after LTH and LASH.
Table 5

Quality of Life after laparoscopic total hysterectomy (LTH) or laparoscopic supracervical hysterectomy (LASH)

 

Kafy et al. 2009 [17]a

Nam et al. 2008 [18]b

LTH 40

LASH 40

LTH 51

LASH 39

Before

After

Before

After

Before

After

Before

After

General health

2.2 ± 0.4

1.9 ± 0.4

2.3 ± 0.5

2.1 ± 0.6

NA

NA

NA

NA

P < 0.001

P < 0.005

NA

NA

Self-image

2.2 ± 0.4

2.1 ± 0.4

2.4 ± 0.5

2.1 ± 0.4

NA

NA

NA

NA

P < 0.01

P < 0.006

NA

NA

NA

NA

Sexual satisfaction

2.5 ± 0.6

2.2 ± 0.5

2.5 ± 0.7

2.3 ± 0.6

1.98

1.9

2.1

1.95

P < 0.001

P < 0.002

NS

NS

Dyspareunia

2.4 ± 0.6

1.7 ± 0.5

1.9 ± 0.7

1.6 ± 0.5

2c

2

4

1

P < 0.001

P < 0.002

NA

NA

Time to intercourse

NA

NA

5.78 ± 1.13

4.92 ± 1.2

    

NA

NA

P < 0.001

aKafy et al.’s scale: 1 very satisfied, 2 satisfied, 3 somewhat satisfied, 4 unsatisfied, 5 very unsatisfied

bNam et al.’s scale: 1 not satisfied, 2 somewhat, 3 satisfied

cNumber of patients

General health and dyspareunia

General health or dyspareunia following LTH and LASH are comparable.

Sexual satisfaction and time to first intercourse

Contrary to a previous report of impaired sexual satisfaction after total hysterectomy [7], Kafy et al. could not demonstrate any difference in sexual satisfaction or self image after LTH or LASH [17]. Nam et al. [18] reported earlier resumption of sexual activity in the LASH group compared to LTH group. This might be related to health personnel’s advice to avoid sexual contact until 6–8 weeks after surgery. Indeed, early sexual intercourse is one of the predisposing factors for vaginal vault prolapse after total hysterectomy [19].

Conclusions

Besides a slightly increased incidence of bladder injury with LTH and of complications related to cervical retention after LASH, the two laparoscopic techniques appear comparable. Both techniques lead to improvement in dyspareunia. Following the studies demonstrating similar sexual function with and without cervical preservation, we performed mainly LTH. In addition to post-LASH cervical bleeding, retaining the cervix is associated with the concerns of cancer development in the cervical stump. This is especially important in the regions with poor follow-up and lack of annual cervical smears. The risk of developing carcinoma in the cervical stump is less than 0.03% in women who had had previous normal cervical cytology [20].

Other cervical stump complications include obstructive mucocele, infection and sepsis [21, 22]. As there is no risk of vault prolapse, LASH could be followed by early resumption of sexual activity [23, 24]. The issue of retaining or removing the cervix along with the uterine body should be discussed thoroughly with the patient. For those opting for cervical preservation, they should be instructed to have annual cervical smear.

We conclude that LASH is an alternative to total laparoscopic hysterectomy with less incidence of bladder injury and earlier resumption of sexual activity. Cervical preservation carries a small risk of bleeding and malignant transformation that might require further intervention. Total laparoscopic hysterectomy requires less postoperative analgesia, has lower incidence of reoperation and eliminates the complications associated with cervical stump. However, it is associated with increased urinary tract injury and rarely with vault prolapse. The decision to perform either procedure depends on the surgeon’s expertise and the preference of both surgeon and the patient.

Declarations

Conflicts of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Authors’ Affiliations

(1)
Department of Obstetrics and Gynecology, McGill University

References

  1. The Canadian Institute for Health Information (2006) Health Indicator Reports; HysterectomyGoogle Scholar
  2. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a1.htm. Accessed 3 Aug 2010
  3. Women’s Health Matters (2002) Hysterectomies too Frequent in Canada? http://www.womenshealthmatters.ca/news/news_show.cfm?number=170. Accessed 3 Aug 2010
  4. Sokol AI, Green IC (2009) Laparoscopic hysterectomy. Clin Obstet Gynecol 52:304–312View ArticlePubMedGoogle Scholar
  5. Jenkins TR (2004) Laparoscopic supracervical hysterectomy. Am J Obstet Gynecol 191:1875–1884View ArticlePubMedGoogle Scholar
  6. Bojahr B, Raatz D, Schonleber G, Abri C, Ohlinger R (2006) Perioperative complication rate in 1706 patients after a standardized laparoscopic supracervical hysterectomy technique. J Minim Invasive Gynecol 13:183–189View ArticlePubMedGoogle Scholar
  7. Kilkku P, Gronroos M, Hirvonen T, Rauramo L (1983) Supravaginal uterine amputation vs. hysterectomy. Effects on libido and orgasm. Acta Obstet Gynecol Scand 62:147–152View ArticlePubMedGoogle Scholar
  8. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I (2002) Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med 347:1318–1325View ArticlePubMedGoogle Scholar
  9. Gimbela H, Zobbea V, Andersena BM, Filtenborge T, Gluudd C, Taborb A, The Danish Hysterectomy Group (2003) Randomised controlled trial of total compared with subtotal hysterectomy with one-year follow up results. BJOG 110:1088–1098View ArticleGoogle Scholar
  10. Learman L, Summit R, Varner RE, McNeeley SG, Goodman-Gruen D, Richter HE, Feng L, Showstack J, Ireland C, Vittinghoff E, Helley SB, Washington AE (2003) A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Obstet Gynecol 102:453–462View ArticlePubMedGoogle Scholar
  11. Harmanli OH, Tunitsky E, Esin S, Citil A, Knee A (2009) A comparison of short-term outcomes between laparoscopic supracervical and total hysterectomy. Am J Obstet Gynecol 201(536):e1–e7PubMedGoogle Scholar
  12. Mueller A, Renner SP, Haeberle L, Lermann J, Oppelt P, Beckmann MW, Thiel F (2009) Comparison of total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH) in women with uterine leiomyoma. Eur J Obstet Gynecol Reprod Biol 144:76–79View ArticlePubMedGoogle Scholar
  13. Mousa A, Zarei A, Tulandi T (2009) Changing practice from laparoscopic supracervical hysterectomy to total hysterectomy. J Obstet Gynaecol Can 31:521–525PubMedGoogle Scholar
  14. Cipullo L, De Paoli S, Fasolino L, Fasolino A (2009) Laparoscopic supracervical hysterectomy compared. JSLS 13:370–375PubMedGoogle Scholar
  15. Milad MP, Morrison K, Sokol A, Miller D, Kirkpatrick L (2001) A comparison of laparoscopic supracervical hysterectomy vs. laparoscopically assisted vaginal hysterectomy. Surg Endosc 15:286–288View ArticlePubMedGoogle Scholar
  16. Van Evert JS, Smeenk JM, Dijkhuizen FP, de Kruif JH, Kluivers KB (2010) Laparoscopic subtotal hysterectomy versus laparoscopic total hysterectomy: a decade of experience. Gynecol Surg 7:9–12View ArticlePubMedGoogle Scholar
  17. Kafy S, Al-Sannan B, Kabli N, Tulandi T (2009) Patient satisfaction after laparoscopic total or supracervical hysterectomy. Gynecol Obstet Invest 67:169–172View ArticlePubMedGoogle Scholar
  18. Nam A, Cho SH, Seo SK, Jeon YE, Kim HY, Choi YS, Lee BS (2008) Laparoscopic total hysterectomy versus laparoscopic supracervical hysterectomy: the effect on female sexuality. Women’s Med 1:43–47Google Scholar
  19. Agdi M, Al-Ghafri W, Antolin R, Arrington J, O’Kelley K, Thomson AJ, Tulandi T (2009) Vaginal vault dehiscence after hysterectomy. J Minim Invasive Gynecol 16:313–317View ArticlePubMedGoogle Scholar
  20. Storm HH, Clemmensen IH, Manders T, Brinton LA (1992) Supravaginal uterine amputation in Denmark 1978–1988 and risk of cancer. Gynecol Oncol 45:198–201View ArticlePubMedGoogle Scholar
  21. Okaro EO, Jones KD, Sutton C (2001) Long term outcome following, aparoscopic supracervical hysterectomy. BJOG 108:1017–1020View ArticlePubMedGoogle Scholar
  22. Huang JYJ, Ziegler C, Tulandi T (2005) Cervical stump necrosis and septic shock after laparoscopic supracervical hysterectomy. J Min Inv Gynecol 12:162–164View ArticleGoogle Scholar
  23. Charles JL, Jamse FD (1996) Early outcomes of laparoscopic assisted vaginal hysterectomy versus laparoscopic supra cervical hysterectomy. J Am Assoc Gynecol Laparosc 3:251–256View ArticleGoogle Scholar
  24. Diaa EM, Wahba MF, Chitranjan LF, Jean MW (2004) Laparoscopic supracervical hysterectomy versus laparoscopic assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 11:175–180View ArticleGoogle Scholar
  25. Morelli M, Noia R, Chiodo D, Mocciaro R, Costantino A, Caruso MT, Cosco C, Lucia E, Curcio B, Gullì G, Amendola G, Zullo F (2007) Laparoscopic supracervical hysterectomy versus laparoscopic total hysterectomy: a prospective randomized study. Minerva Gynecol 59:1–10Google Scholar

Copyright

© Springer-Verlag 2010