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Evidence summaries

Total Versus Subtotal Hysterectomy for Benign Gynaecological Conditions

Total vs. subtotal hysterectomy for benign gynaecological conditions appears to have no difference in the rates of incontinence, constipation or measures of sexual function in long-term. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 9 trials with a total of 1 553 women. There was no evidence of a difference in the rates of incontinence, constipation or measures of sexual function between total hysterectomy (TH) and subtotal hysterectomy (STH), either in the short term (up to two years post-surgery) or long term (nine years post-surgery). Length of surgery and amount of blood lost during surgery were reduced during subtotal hysterectomy when compared with total hysterectomy, but there was no evidence of a difference in the odds of transfusion. Febrile morbidity was less likely and ongoing cyclical vaginal bleeding one year after surgery was more likely after subtotal when compared with total hysterectomy. There was no difference in the rates of other complications, recovery or readmission rates.

A meta-analysis 2 comparing total versus subtotal hysterectomy included 11 RCTs involving 1523 patients. Operative time (mean difference: 12.88 minutes, 95% CI 7.45 to 18.30), hospital stay (MD 0.44 days, 95% CI 0.11 to 0.77), and intraoperative blood loss (MD 81.06 ml, 95% CI 9.16 to 152.97) favored STH over TH, although the rate of blood transfusion did not differ between the groups. Conversely, TH group had less cyclical vaginal bleeding over SH (1.2% versus 14.1%; RR 0.14 95% CI 0.05 to 0.43) during one-year follow up. Persistent pain and sexual satisfaction rates, and quality of life scores were similar up to 12 months follow up.

Another meta-analysis 3 comparing pelvic floor symptoms after total versus subtotal hysterectomy included 4 RCTs involving 566 patients. Follow-up ranged from 5 to 14 years. Risk of urinary incontinence (RR 0.74, 95 % CI 0.58 to 0.94) and stress urinary incontinence (RR 0.84, 95% CI 0.71 to 0.99) were nonsignificantly (P 0.02 and 0.04 respectively) lower with TH than with STH. The events urinary frequency, urge incontinence, incomplete bladder emptying, pelvic organ prolapse, incontinence of stool and constipation did not favor one procedure over another in the long term.

Comment: The quality of evidence is downgraded by study quality (lack of blinding in half of trials).

    References

    • Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev 2012;(4):CD004993. [PubMed]
    • Aleixo GF, Fonseca MCM, Bortolini MAT et al. Total Versus Subtotal Hysterectomy: Systematic Review and Meta-analysis of Intraoperative Outcomes and Postoperative Short-term Events. Clin Ther 2019;41(4):768-789. [PubMed]
    • Aleixo GF, Fonseca MCM, Bortolini MAT et al. Pelvic floor symptoms 5 to 14 years after total versus subtotal hysterectomy for benign conditions: a systematic review and meta-analysis. Int Urogynecol J 2019;30(2):181-191. [PubMed]

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