Choosing The Route of Hysterectomy

Here’s the RoshReview Question of the Week!

​​A 49-year-old P3003 woman presents to the clinic with a complaint of heavy menses for several years and asks for definitive management. She has a history of type 4 fibroids, all < 3 cm, and hypercholesterolemia. Her obstetrical history is significant for two vaginal deliveries and one cesarean section. On physical examination, her BMI is 31 kg/m2. Her uterus is anteverted, and the fundus reaches 3 fingerbreadths below the umbilicus. What surgical intervention would be most cost- and clinically effective for this patient?

• Hysteroscopy with tissue removal system

• Open abdominal hysterectomy

• Uterine artery embolization

• Vaginal hysterectomy

Check if you got the right answer at the links above!

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Reading: Committee Opinion 701 - Choosing the Route of Hysterectomy for Benign Disease 

Why do we do a hysterectomy?  

• Hysts are one of the most common surgeries in the United States (per the CDC, over 600,000 are performed annually) 

• Many of them are elective - ie. patients are choosing surgical option over medical for example  

• Reasons for hysterectomy - so many! We review this in some of our other topics such as

  • Uterovaginal Prolapse (Episode 35) - https://creogsovercoffee.com/notes/2019/5/5/uterovaginal-prolapse

  • Abnormal Uterine Bleeding (Episode 47) - https://creogsovercoffee.com/notes/2019/7/28/abnormal-uterine-bleeding-the-basics

  • Acute Uterine Bleeding (Espresso Episode 8) - https://creogsovercoffee.com/notes/2021/7/11/espresso-acute-uterine-bleeding

  • Gestational Trophoblastic Disease (Episode 55) - https://creogsovercoffee.com/notes/2019/9/29/4c3svbxi5jlecxdrk1tnvoykxs1y5h

  • Endometrial Cancer (Episode 69) - https://creogsovercoffee.com/notes/2020/1/12/endometrial-cancer

  • Fibroids (Episode 81) - https://creogsovercoffee.com/notes/2020/4/12/fibroids

  • Cervical Cancer (Episode 101) - https://creogsovercoffee.com/notes/2020/12/6/cervical-cancer

  • Placenta Accreta (Episodes 113-114)

    • https://creogsovercoffee.com/notes/2021/3/7/placenta-accreta-part-i

    • https://creogsovercoffee.com/notes/2021/3/14/placenta-accreta-part-ii-management

  • Endometriosis (Episode 142-143)

    • https://creogsovercoffee.com/notes/2021/10/3/endometriosis-part-i-evaluation-and-diagnosis

    • https://creogsovercoffee.com/notes/2021/10/10/endometriosis-part-ii-treatment 

  • Just to name a few… and remember, we will only discuss benign reasons 

What exactly are the ways to do a hyst anyway and why does route matter?

Note: We won’t go into exact techniques here since we are a podcast. However, some great resources include the Atlas of Pelvic Surgery online: http://www.atlasofpelvicsurgery.com/home.html

Also the textbook by Baggish and Karam: Atlas of Pelvic Anatomy and Gynecologic Surgery 

Vaginal hysterectomy 

• First type of minimally invasive hysterectomy 

• Advantages 

  • Preferred type of hysterectomy when possible due to no incisions on the abdomen and minimally invasive route 

  • High safety and low cost

    • Meta-analysis of seven trials report similar rates of visceral injury and long-term complication among vaginal and laparoscopic procedures 

  • Minimally invasive approach associated with faster recovery compared to laparotomy 

• Disadvantages

  • Unfortunately, despite advantages, there are fewer vaginal hysts performed compared to others due to limited training, fewer numbers of hysts overall being performed and greater diversity of operative approaches 

  • Must remove cervix with this type of procedure - no option for supracervical hyst 

  • Small chance of converting to laparotomy 

Laparoscopic hysterectomy 

• Usually performed with laparoscopic instruments via 3-4 small ports in the abdomen. Uterus can be morcellated and removed through a bag (morcellate in bag) or via the vagina 

• Increasing in popularity 

• Advantages 

  • Better visualization with minimally invasive surgery 

  • Can perform supracervical hyst if needed 

  • Can also perform last part vaginally for ease if needed 

  • May be easier in some obese patients 

• Disadvantages 

  • Requires surgeon skilled in use of laparoscopy 

  • Certain patient populations with certain medical illnesses may not tolerate Trendelenburg position or pneumoperitoneum 

  • Possibility of conversion to laparotomy 

  • Slightly higher rate of vaginal cuff dehiscence compared to other routes of hyst (still low, like 0.64-1.1%) 

Robotic hysterectomy 

• Very similar overall in terms of advantages and disadvantages to laparoscopic hysterectomy due requiring Trendelenburg and pneumoperitoneum, as well as minimally invasive course 

• Advantages 

  • Superior visualization compared to traditional laparoscopy due to ability to move camera and 3D vision 

  • Mechanical improvement - wrists with robots 

  • Better stabilization of instruments 

  • Improved ergonomics for surgeons - you can sit down (as someone who has definitely passed out during a long case) 

  • Even more options for minimally invasive routes (ie. single port hyst) 

• Disadvantages 

  • Additional surgical training 

  • Does not necessarily decrease time (in fact can increase cost and operating room times) 

    • Cost of instruments overall + cost of robot 

  • Lack of haptics (no tactile feedback) 

Abdominal hysterectomy  

• Only non minimally-invasive technique 

• Advantages

  • Visualization 

  • Ability to remove large masses and large uteruses 

  • Tactile feedback  

  • Lowest risk of vaginal cuff dehiscence compared to other methods 

  • Studies like the VALUE study and the eVALuate trial showed decreased rates of complications of abdominal hyst compared to laparoscopic hyst, but these studies are also old (1990s) 

• Disadvantages 

  • Increased postoperative pain and length of stay (average LOS is 3 days after abdominal hyst) 

  • Increased risk of bleeding and infection 

  • Increased risk of VTE (also may be due to increased stasis) 

  • Increased risk of colonic stasis 

How do we pick the route of hysterectomy? 

Consideration of minimally invasive routes 

• MIS should be considered whenever possible because of well-documented advantages over abdominal hysterectomy 

• Vaginal hyst is preferred over other types due to cost, effectiveness, and overall outcomes 

• Even if opportunistic salpingectomy is desired, these can be performed with vaginal hysterectomy 

Anatomy 

• Size and shape of vagina and uterus + descent of uterus 

• More difficult to perform a vaginal hysterectomy if there is no descent, if there is large uterus (bulky fibroids) and small introitus 

  • However, nulliparity is not a contraindication to vaginal hysterectomy 

  • Study showed that 92% of vaginal hysterectomies planned for women with no prior vaginal deliveries could be successfully completed 

• Accessibility of the uterus also important - is there likely to be a lot of pelvic adhesive disease? (endometriosis) 

  • Large uterine size - morcellation has come under scrutiny previously 

  • However, still can morcellate in a bag 

  • Even if large, bulky uterus, can refer to skilled MIS surgeon

• Need of concurrent procedures (ie. will the patient need their appendix removed as well?) 

• Work up: 

  • Physical exam with evaluation of mobility of uterus on bimanual 

  • Evaluation for adnexal masses on bimanual 

  • Feel for fundal height 

  • Pelvic ultrasound may be helpful 

Surgeon comfort/preference 

• Surgeon preference for other operative routes - no longer considered an appropriate reason to avoid vaginal approach 

• Surgeon experience 

  • Average case volume

  • Available hospital technology, devices, and support 

Patient preference 

• If patient desires supracervical hysterectomy, will need laparoscopic or abdominal approach 

• However, no clinically significant difference in complication and uncertain benefit in terms of patient outcomes (ie. sexual function, urinary function, bowel function)

ACOG CO 701

Placenta Accreta Part II: Management

After last week’s initial episode, we talk through some pearls for management. Keeping it simple today:

• Antenatal care considerations:

  • Pelvic rest, avoid travel - don’t get into a bad situation!

  • Prenatal care is fairly routine.

  • Hospitalization practices will vary by region and level of resources — i.e., admission for proximity. Bleeding should prompt admission, likely until delivery.

  • Sweet spot for delivery typically between 34-35’6 weeks, though some centers pushing towards 36+ weeks.

    • However, as Dr. Einerson mentions, the worst thing you can do is end up in an emergent delivery scenario with these patients!

  • Don’t forget about using late preterm steroids!

• Cesarean hysterectomy tips:

  • Collins 2019 paper on evidence-based management. Don’t deliver too late!

  • Multidisciplinary / interdisciplinary care leads to less morbidity.

  • Ureteral stents: if you need them to identify ureters to safely perform surgery.

  • Some tips from our guests:

    • Approach through VML skin incision, though Maylard / Cherney incisions are also reasonable. Fundal hysterotomy (typically) to avoid messing with the placenta.

    • Decrease blood flow before addressing the bladder - they often take the uterine vessels before developing the bladder.

    • Arterial catheters such as the REBOA are to be used in experimental settings only, and are associated with serious complications.

    • If bleeding - the most experienced operators need to be there.

    • Bipolar vessel sealing devices (such as LigaSure) are helpful!

• Conservative management?

  • To be done only on an experimental basis at this time! Reasonable to examine in a trial for a number of reasons.

  • Methotrexate does NOT work for retained placenta — MTX kills rapidly dividing cells, not stagnant cells left behind.

• Patient resources / advocacy:

  • Check out the National Accreta Foundation as a great patient advocacy resource.

Placenta Accreta Part I - Pathophysiology, Diagnosis, and Imaging

Today we welcome two special guests to the podcast — Dr. Scott Shainker, who is an assistant professor at Beth Israel Deaconess in Boston, MA, and Dr. Brett Einerson, who is an assistant professor at the University of Utah in Salt Lake City, UT. Both Dr. Shainker and Dr. Einerson are experts in the world of placenta accreta spectrum, with numerous publications, guideline papers, and advocacy efforts to their names. We did a two part series with them on PAS. This first episode, we focus on pathology, diagnosis, and imaging. Next week, we’ll get into management and future directions.

For further reading, check out ACOG’s Obstetric Care Consensus on PAS.

PAS has traditionally been thought of as an “invasive” disease, but that thinking is evolving to think of PAS as a disease of uterine dehiscence. The loss of the uterine decidua due to prior uterine scarring (i.e., due to surgery) brings about abnormal attachment and a “superhighway of vascularity,” thus that when delivery comes, the placenta fails to separate normally. Uterine muscle dehiscence likely accounts for the degree of invasiveness. It’s likely that cesarean scar pregnancies are a precursor to PAS.

https://resident360.nejm.org/clinical-pearls/placenta-accreta-spectrum

The PAS diagnosis and terminology is also changing, from the traditional accreta / increta / percreta divide seen above, to a FIGO staging system with both surgical and pathologic criteria. You can review those here.

We review some of the risk factors, but far and away the biggest is a combination of a prior cesarean and placenta previa. Dr. Shainker mentions Dr. Robert Silver’s landmark paper on this - the percentages are worth committing to memory. Other risk factors include other types of uterine surgery like abdominal myomectomy; IVF and ART; and potentially dilation and curettage, though that is controversial.

Imaging is great in research capacities with high sensitivity (approaching 90+%), but only 50% of patients with accreta know about it before delivery. So the real world sensitivity is very poor. Risk factors should raise suspicion primarily, and the use of imaging help guide your preoperative suspicion. SMFM has now published a consensus on ultrasound diagnosis, which is the gold standard. More data should hopefully improve the real-world detection rates for PAS.