Trachelectomy Following Supracervical Hysterectomy

Introduction

Currently in the United States, >600,000 hysterectomies are performed annually, 90% of which are for benign disease. ¹ Before 1950, ∼ 95% of hysterectomies were done via a supracervical approach, because it avoided entry into the vagina, shortened the duration of anesthesia, and reduced the incidence of visceral and hemorrhagic complications. With improvements in surgical training and techniques during the second half of the 20th century, total hysterectomy became the standard of care and supracervical hysterectomy was relegated to situations where removal of the cervix was deemed to be prohibitive. ²

A resurgence in supracervical hysterectomy started in the 1990s because of expanding technology and techniques of minimally invasive surgery, including laparoscopy with or without robotic assistance, or uterine morcellation. The rate of supracervical hysterectomy has hence increased by > 400%, and now represents > 8% of all hysterectomies performed for benign disease.^3,4

Problems with retention of the cervical stump have been reported in 5%–22% of patients undergoing supracervical hysterectomy, including persistent vaginal bleeding, prolapse, cervical dysplasia or cancer, and noncervical cancers. ⁵ Cases of trachelectomy (removal of the retained cervical stump) following supracervical hysterectomy were reviewed to evaluate the indications for prior supracervical hysterectomy and subsequent trachelectomy as well as estimate the proportion of women who will require trachelectomy after supracervical hysterectomy, were reviewed.

Materials and Methods

A retrospective case series was performed for all women who underwent trachelectomy at Northwestern University's Prentice Women's Hospital between January 1, 1999 and October 1, 2009. Institutional Review Board of Northwestern University approval was obtained prior to the data collection. Cases, as well as the number of supracervical hysterectomies during the time period, were identified through a hospital database of surgical admissions. All cases of trachelectomy following supracervical hysterectomy were included in the analysis.

The hospital charts, including operative notes and pathology reports, of 27 women meeting the inclusion criteria were abstracted for demographic and medical data. Details of the original supracervical hysterectomy were collected, including type of surgery performed, indications for hysterectomy, reason for the supracervical approach if known, surgical modality (i.e., laparoscopic or robotic assisted with our without uterine morcellation, or mini-laparotomy vs. open abdominal), and original pathology. The preoperative workup was also evaluated, including assessment of up-to-date cervical cancer screening and performance of endometrial biopsy, if indicated. Trachelectomy data collected included indications for trachelectomy, surgical modality (i.e., laparoscopic, robotic assisted, vaginal, or open abdominal), estimated blood loss, complications, length of hospital stay, and histology of the cervical stump.

Results

During the almost 11-year study period, 27 women who had had prior supracervical hysterectomy underwent trachelectomy at Northwestern University's Prentice Women's Hospital. Twelve of these women had had their original surgery at Northwestern, which represented 0.9% of the 1,337 supracervical hysterectomies performed during the same time period.

Prior supracervical hysterectomy had been performed via laparotomy in 20 women (74%) and laparoscopically in 7 women (26%). For those undergoing laparoscopic surgery, a morcellator had been used to aid in removing the uterine tissue. The indications for supracervival hysterectomy are listed in Table 1, with fibroids being the most common (59%). Twenty-three of the 27 women had an appropriate preoperative workup before the supracervical hysterectomy, including up-to-date cervical cancer screening and an endometrial biopsy if clinically indicated; 3 had an unknown preoperative evaluation, and 1 did not have a documented endometrial biopsy.

In 75% of cases, there was no documentation in the chart reflecting surgeon counseling or a preoperative reason for retaining the cervix. The operative report in 1 case noted difficulty in removing the cervix, which led to an intraoperative decision for supracervical hysterectomy. In another case, the operative report included removal of the cervix; however, a portion of the cervix was unintentionally left in situ. Of the 4 cases with a documented preoperative reason for retention of the cervix, 2 were for patient preference and 2 were for prolapse prevention.

Pathology from the supracervical hysterectomy revealed malignancy in 9 (33%) of the 27 cases (Table 1). Four patients had uterine sarcomas: 3 endometrial stromal sarcomas and 1 leiomyosarcoma. Five patients had endometrial adenocarcinomas: 1 was perimenopausal with menorrhagia, 2 were postmenopausal with “symptomatic fibroids,” 1 was premenopausal with fibroids, and 1 had a preoperative diagnosis of complex atypical endometrial hyperplasia.

Trachelectomy was performed 2 weeks to 18 years following supracervical hysterectomy. Of the 27 patients who underwent trachelectomy, mean age was 48 years (range 29–74 years) and mean gravity and parity were 2.6 and 2.0, respectively. Trachelectomies were most often performed vaginally for benign conditions (44%), whereas the abdominal approach, either open (37%) or laparoscopic (19%), was chosen for malignant conditions when additional staging procedures were undertaken. Minor complications of trachelectomy occurred in 2 patients; 1 patient had a prolapsed fallopian tube and 1 patient had a postoperative fever. The only major complication of trachelectomy was a vesicovaginal fistula, which occurred in a patient undergoing laparoscopic trachelectomy as well as staging procedures; this resolved with conservative management. Significant adhesions were noted in 26% of operative reports. The mean estimated blood loss was 300 cc, and the average hospital stay was 2.6 days. There was no evidence of disseminated disease at the time of trachelectomy as a result of uterine morcellation during laparoscopic supracervical hysterectomy in patients with cancer.

The indication for and the pathology of the trachelectomies are provided in Table 2. Sixteen (59%) of the trachelectomies were performed for cancer, including 9 uterine malignancies, 2 interval cervix cancers, and 5 interval cervical intraepithelial neoplasias. Benign indications for trachelectomy were bleeding (5), pain (2), prolapse (2), cervical fibroid (1), and a pelvic mass (1). Pathologic examination of the cervical stump revealed residual cancer in 3 (11%), cervical intraperitoneal neoplasia in 6 (27%), and no residual or benign disease in 18 (67%).

Discussion

The need for trachelectomy for symptoms or neoplasia has been reported to occur in up to 23% of patients following supracervical hysterectomy. ⁵ In this series, 27 women underwent trachelectomy over an 11-year period. Of these 27 cases of trachelectomy, 12 had their antecedent hysterectomy performed at this institution, during which time 1,337 supracervical hysterectomies were performed for a relative incidence of 0.9%. Although the necessity for post-supracervical hysterectomy trachelectomy seems low, a disturbing finding in this series was the high incidence of neoplasia (59%) as an indication for trachelectomy. Of the 27 trachelectomies performed, 9 (33%) were for the pathologic finding of uterine malignancy in the supracervical hysterectomy specimen and 7 (26%) were for the subsequent development of cervical intraepithelial neoplasia (5) or cancer (2). The most common indications for trachelectomy in other series were cyclical vaginal bleeding, pelvic pain, and prolapse.^6–8 In two reports, cervical dysplasia or cancer accounted for only 11% and 12% of indications for trachelectomy.^6,7

Supracervical hysterectomy is gaining renewed interest among patients because of unsupported information on the benefits of preserving the cervix for sexual function and pelvic support, as well as among some gynecologic surgeons because of presumed decreased morbidity and ease of laparoscopic approach. Randomized clinical trials specifically addressing sexual dysfunction, ^9–12 urinary dysfunction,^13–15 perioperative morbidity,^15–17 and long-term outcomes ¹⁸ have failed to demonstrate any advantage of supracervical hysterectomy over total hysterectomy. A meta-analysis of 34 randomized clinical trials and observational studies comparing total and subtotal hysterectomy for benign indications concluded that urinary incontinence and prolapse were less frequent after total hysterectomy; quality of life, constipation, pelvic pain, and sexual experience were not influenced by either hysterectomy method; and operative time, intraoperative bleeding, and preoperative complications (mostly fever) were less with subtotal hysterectomy, although the differences were small and unlikely to be of clinical importance.

Conclusions

Patients electing to undergo supracervical hysterectomy should be counseled comprehensively and accurately about the lack of data demonstrating clear benefits over total hysterectomy, as well as the 5%–22% incidence of persistent cyclical vaginal bleeding; the possible need for subsequent trachelectomy for bleeding, pain, prolapse or neoplasia; and the requirement for long-term follow-up.

Despite this information on lack of superiority and known associated risks of supracervical hysterectomy, a survey of gynecologists reported that only 18% of respondents regularly counseled women preoperatively regarding the advantages and disadvantages of both total and subtotal hysterectomy. ¹⁹ Committee Opinions/Guidelines from both the American College of Obstetricians and Gynecologists and the Society of Obstetricians and Gynecologists of Canada state that the supracervical approach should not be recommended as a superior technique for hysterectomy.^20,21