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Complications of hysterectomy
LETTERS TO THE EDITOR
Complications of Hysterectomy To the Editor: Deliberate decisions to perform most hysterectomies by the vaginal route may not necessarily be in the best interests of the patient.1 Division of healthy (nonattenuated) uterosacral ligaments not only diminishes the support of the superior vaginal segment but also divides the nerve bundles contained within them.2 These nerves appear to supply the upper vagina and contain parasympathetic ganglia. Extensive dissection of the uterovesical fold at vaginal hysterectomy may also compromise the nerve supply to the vesical neck and anterior vaginal wall. Abdominal hysterectomy can be performed with minimal, sharp dissection of the uterovesical fold and removal of the cervix without division of the uterosacral ligaments that insert predominantly into the superior vaginal fornix (an intrafascial hysterectomy). The third clamp is applied to the level of the superior border of the ligament with the uterus and cervix being removed by a circumferential incision of the superior vaginal fornix. Surgical planning should give attention to the quality of the uterosacral support of the superior vaginal segment. There is no dichotomy between subtotal and total abdominal hysterectomy. The absence of reliable, medium term (5–10 years), prospective information about the consequences of any form of hysterectomy is an important omission in the gynecological literature. Increasing apprehension about the rates of subsequent surgery for stress and urge urinary incontinence, genital prolapse, and ovarian complications should make this a pre-eminent concern in contemporary gynecological practice. Any form of hysterectomy in parous subjects with prior intrapartum damage may be the decisive event that commits a woman to regular, subsequent, reconstructive pelvic surgery. Increasing scrutiny of the indications for many kinds of gynecological surgical intervention should be anticipated if we are unable to answer such fundamental questions. Martin Quinn, MD, MRCOG Hinchingbrooke Hospital Huntingdon, United Kingdom
518
0029-7844/01/$20.00
REFERENCES 1. Varma R, Tahseen S, Lokugamage AU, Kunde D. Vaginal route as the norm when planning hysterectomy for benign conditions: Change in practice. Obstet Gynecol 2001;97: 613– 6. 2. Campbell RM. The anatomy and histology of the sacrouterine ligaments. Am J Obstet Gynecol 1950;59:1–12.
In Reply: The concerns raised by Dr. Quinn have no scientific basis. We do agree that there are no data regarding the long-term effects of either the vaginal or abdominal route of hysterectomy. There is, however, a recent systematic review that has addressed the issue of urinary incontinence after hysterectomy.1 This review shows a significantly higher incidence of urinary incontinence after a hysterectomy, but there is no distinction between the two routes addressed in our study. As the abdominal route is the predominant route, we could extrapolate that the majority of patients in this review had their hysterectomy abdominally. Hysterectomy may lead to damage to pelvic nerves2 or pelvic supportive structures.3 There are no data to support the belief that these risks are any greater in the hysterectomy by vaginal route. With regards to the dissection and division of uterosacral ligaments, the dissection we perform is no more extensive than what is
Intrafascial hysterectomy. The uterus and cervix have been removed without division of the uterosacral ligaments. Two Littlewoods forceps have been placed on the anterior and posterior vaginal walls with a Spencer Wells clamp on the paracolpium. The uterosacral ligaments may be seen beneath the Littlewoods forceps on the posterior vaginal wall. Quinn. Letter to the Editor. Obstet Gynecol 2001.
OBSTETRICS & GYNECOLOGY
Complications of Hysterectomy To the Editor: Deliberate decisions to perform most hysterectomies by the vaginal route may not necessarily be in the best interests of the patient.1 Division of healthy (nonattenuated) uterosacral ligaments not only diminishes the support of the superior vaginal segment but also divides the nerve bundles contained within them.2 These nerves appear to supply the upper vagina and contain parasympathetic ganglia. Extensive dissection of the uterovesical fold at vaginal hysterectomy may also compromise the nerve supply to the vesical neck and anterior vaginal wall. Abdominal hysterectomy can be performed with minimal, sharp dissection of the uterovesical fold and removal of the cervix without division of the uterosacral ligaments that insert predominantly into the superior vaginal fornix (an intrafascial hysterectomy). The third clamp is applied to the level of the superior border of the ligament with the uterus and cervix being removed by a circumferential incision of the superior vaginal fornix. Surgical planning should give attention to the quality of the uterosacral support of the superior vaginal segment. There is no dichotomy between subtotal and total abdominal hysterectomy. The absence of reliable, medium term (5–10 years), prospective information about the consequences of any form of hysterectomy is an important omission in the gynecological literature. Increasing apprehension about the rates of subsequent surgery for stress and urge urinary incontinence, genital prolapse, and ovarian complications should make this a pre-eminent concern in contemporary gynecological practice. Any form of hysterectomy in parous subjects with prior intrapartum damage may be the decisive event that commits a woman to regular, subsequent, reconstructive pelvic surgery. Increasing scrutiny of the indications for many kinds of gynecological surgical intervention should be anticipated if we are unable to answer such fundamental questions. Martin Quinn, MD, MRCOG Hinchingbrooke Hospital Huntingdon, United Kingdom
518
0029-7844/01/$20.00
REFERENCES 1. Varma R, Tahseen S, Lokugamage AU, Kunde D. Vaginal route as the norm when planning hysterectomy for benign conditions: Change in practice. Obstet Gynecol 2001;97: 613– 6. 2. Campbell RM. The anatomy and histology of the sacrouterine ligaments. Am J Obstet Gynecol 1950;59:1–12.
In Reply: The concerns raised by Dr. Quinn have no scientific basis. We do agree that there are no data regarding the long-term effects of either the vaginal or abdominal route of hysterectomy. There is, however, a recent systematic review that has addressed the issue of urinary incontinence after hysterectomy.1 This review shows a significantly higher incidence of urinary incontinence after a hysterectomy, but there is no distinction between the two routes addressed in our study. As the abdominal route is the predominant route, we could extrapolate that the majority of patients in this review had their hysterectomy abdominally. Hysterectomy may lead to damage to pelvic nerves2 or pelvic supportive structures.3 There are no data to support the belief that these risks are any greater in the hysterectomy by vaginal route. With regards to the dissection and division of uterosacral ligaments, the dissection we perform is no more extensive than what is
Intrafascial hysterectomy. The uterus and cervix have been removed without division of the uterosacral ligaments. Two Littlewoods forceps have been placed on the anterior and posterior vaginal walls with a Spencer Wells clamp on the paracolpium. The uterosacral ligaments may be seen beneath the Littlewoods forceps on the posterior vaginal wall. Quinn. Letter to the Editor. Obstet Gynecol 2001.
OBSTETRICS & GYNECOLOGY