Hysterectomy (benign indications): Selection of surgical route

INTRODUCTION — While an open abdominal incision has historically been required for hysterectomy, the surgery has evolved into multiple types of procedures each with its own benefits and limitations. Beyond the traditional abdominal approach, hysterectomy can be performed vaginally or laparoscopically, and the development of robot-assisted systems has added variations for both of these. In addition, routes can be combined.

This topic review will review the data and clinical issues that impact selection of hysterectomy route. Topics on specific hysterectomy techniques are reviewed separately.

●(See "Hysterectomy: Vaginal".)

●(See "Hysterectomy: Laparoscopic".)

●(See "Hysterectomy: Abdominal (open) route".)

●(See "Prophylactic vaginal apex suspension at the time of hysterectomy".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage readers to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

HYSTERECTOMY INDICATIONS AND ALTERNATIVES

●Indication for hysterectomy – There are five broad diagnostic categories of indications for hysterectomy:

•Uterine leiomyomas

•Abnormal uterine bleeding

•Pelvic organ prolapse (POP)

•Pelvic pain or infection (eg, endometriosis, pelvic inflammatory diseases)

•Malignant and premalignant disease

●Treatment alternatives – Medical and surgical alternatives to hysterectomy depend upon the underlying disorder. As an example:

•Uterine fibroids – Uterine artery embolization and myomectomy may be used to treat symptomatic leiomyoma [1]. (See "Uterine fibroids (leiomyomas): Treatment overview", section on 'Uterine artery embolization'.)

•Pelvic organ prolapse – POP can be treated nonsurgically with pelvic floor exercises or pessaries. (See "Vaginal pessaries: Indications, devices, and approach to selection".)

•Chronic pelvic pain – Pain control interventions, including hormonal therapy such as with contraceptives, may help patients manage intractable pelvic pain (eg, endometriosis) and restore functional status without surgery.

-(See "Endometriosis: Treatment of pelvic pain".)

-(See "Chronic pelvic pain in nonpregnant adult females: Causes".)

-(See "Chronic pelvic pain in adult females: Treatment".)

•Heavy menstrual bleeding – Medical therapies, endometrial ablation, and medicated intrauterine devices may be effective therapies for excessive uterine bleeding. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management", section on 'Treatment selection'.)

•Endometriosis – Medical therapy can help reduce discomfort associated with endometriosis. (See "Endometriosis: Treatment of pelvic pain".)

•Endometrial hyperplasia – Endometrial hyperplasia can sometimes be treated medically with progestins. (See "Endometrial hyperplasia: Clinical features, diagnosis, and differential diagnosis".)

•Cervical intraepithelial neoplasia – Conization (eg, cold knife, loop electrosurgical excision procedure) may be adequate therapy for some patients with high grade cervical intraepithelial neoplasia/carcinoma in situ. (See "Cervical intraepithelial neoplasia: Management" and "Cervical intraepithelial neoplasia: Diagnostic excisional procedures".)

ROUTE OF HYSTERECTOMY FOR BENIGN DISEASE

Our approach — For patients with benign gynecologic disease, we proceed in the order below, as possible based on patient characteristics and preferences (algorithm 1):

●Vaginal route – Vaginal hysterectomy is the preferred approach for most patients because of its documented advantages and relatively lower complication rates [2-4].

●Laparoscopic route – If a vaginal hysterectomy is not feasible because of limited vaginal access, the size of the uterus, or major adhesive disease, then laparoscopic hysterectomy is performed. In some cases, robot-assisted laparoscopy is performed, and the decision to use robotic assistance is usually based on surgeon preference and available resources. Minimally invasive approaches (laparoscopy or robotic-assisted laparoscopy) are preferred to laparotomy because of decreased morbidity and mortality [5].

●Laparotomy – Hysterectomy by laparotomy is reserved for all other cases. The supporting data for this approach are described below. (See 'Comparison of routes of hysterectomy' below.)

Trends in surgical route — Despite the data and position statements supporting the vaginal approach as the preferred route for hysterectomy, the trend has been toward laparoscopic approaches. A secondary analysis of the United States National Surgical Quality Improvement Program Database that included over 161,000 women undergoing vaginal or laparoscopic hysterectomy reported [6]:

●Change in distribution of surgical approaches – Between 2008 and 2018, vaginal hysterectomy rates dropped from 51 to 13 percent while rates for total laparoscopic hysterectomy increased from 12 to 68 percent [6].

●Change in distribution of complications – Laparoscopic hysterectomy performed in the US between 2008 and 2018 was associated with reduced odds of both major and minor complications compared with vaginal hysterectomy [6]. While this study reported overall complication rates, other data sets have reported increased risk of specific complications (vaginal cuff dehiscence and need for conversion to open abdominal surgery) with laparoscopic hysterectomy compared with vaginal surgery [7]. (See 'Vaginal hysterectomy' below.)

The review of hysterectomies performed in the US between 2008 and 2018 reported the following major and minor complication rates [6]:

•Total laparoscopic hysterectomy – Major complications adjusted odds ratio [aOR] 0.813, 95% CI 0.75-0.88 and minor complications aOR 0.72, 95% CI 0.68-0.77.

•Laparoscopic-assisted vaginal hysterectomy – Major complications aOR 0.87, 95% CI 0.80-0.96 and minor complications aOR 0.90, 95% CI 0.83-0.96.

COMPARISON OF ROUTES OF HYSTERECTOMY — Each surgical route has unique considerations, including time to normal activity, duration of hospitalization, technical feasibility, operating time, and risk of injury. The main body of evidence is from a 2015 meta-analysis of 47 randomized trials, including over 5000 individuals undergoing hysterectomy, comparing abdominal, laparoscopic, and vaginal routes of hysterectomy [3].

Vaginal hysterectomy — Vaginal hysterectomy is the preferred route of hysterectomy, when technically feasible, because it is associated with better outcomes and fewer complications compared with traditional abdominal and total laparoscopic hysterectomy (table 1) [3,7]:

●Vaginal hysterectomy versus abdominal hysterectomy [3]:

•Quicker return to normal activities by approximately 12 days

•Reduction of hospital stay by approximately one day

●Vaginal hysterectomy versus total laparoscopic hysterectomy (ie, the entire surgery is performed laparoscopically):

•Vaginal route – Vaginal hysterectomy is associated with shorter operative time (range of 17 to 42 minutes on average) [3,7].

•Laparoscopic route – When compared with vaginal hysterectomy, a 2017 meta-analysis including 24 articles (trials and observational studies) reported the following for total laparoscopic hysterectomy [7]:

-Advantages – When compared with vaginal hysterectomy, laparoscopy was associated with lower postoperative pain scores on visual analog scale (mean difference [MD] -1.08, 95% CI -1.70 to -0.42), less analgesia use for a shorter period of time (MD -0.64 days, 95% CI -1.06 to -0.22), and reduced length of stay (one versus two days) [7,8]. The clinical significance of the differences in pain outcomes is likely small and the length-of-stay data are from surgeries performed between 2006 and 2015, which may no longer be valid.

-Disadvantages – Compared with vaginal hysterectomy, laparoscopy was associated with higher risks of vaginal cuff dehiscence (odds ratio [OR] 6.3, 95% CI 2.4-16.6) and conversion to laparotomy (OR 3.9, 95% CI 2.2-6.9) [7].

●Vaginal robot-assisted surgery – A robotically-assisted device for vaginal hysterectomy (commercial name Hominis Surgical System) utilizes a single vaginal port with robot-controlled instruments and a traditional transabdominal laparoscopic video camera for visualization [9,10]. Comparative data on patients who may benefit from this approach, surgical outcomes, and cost compared with other types of hysterectomy are not yet available. In a pilot observational study of 30 females who underwent vaginal robot-assisted hysterectomy, all procedures were completed as planned without conversion to another route, no intraoperative complications occurred, medial blood loss was 50 mL (range 20-400 mL), and median procedure duration was 57 minutes (range 24-88 minutes) [11]. Pelvic support procedures, such as uterosacral ligament suspension, can be performed as part of vaginal robot-assisted hysterectomy [12].

This technology has also been used for other types of transvaginal natural orifice transluminal surgery (vNOTES), including bilateral salpingo-oophorectomy, omentectomy, and vaginal uterosacral ligament suspension [12-15]. This system is a potential alternative for both traditional transabdominal laparoscopy and open abdominal surgery. Proposed benefits compared with traditional laparoscopic surgery include reduced postoperative pain, faster recovery, and improved cosmesis [16].

Laparoscopic hysterectomy

Conventional — When vaginal hysterectomy is not possible, laparoscopic hysterectomy has several advantages over the abdominal route, but also has a longer operative time and an increased risk of urinary tract injury [3]. However, in comparison with abdominal hysterectomy, a study reported that there was no duration of surgery at which abdominal hysterectomy was associated with reduced morbidity or length of stay compared with laparoscopic hysterectomy, and thus laparoscopic hysterectomy was preferable when possible [17]. (See "Hysterectomy: Laparoscopic".)

Review of data — A meta-analysis of 21 randomized trials that compared a variety of laparoscopic hysterectomy techniques (laparoscopic-assisted vaginal hysterectomy, laparoscopic hysterectomy with a vaginal cuff closure, total laparoscopic hysterectomy, single-port laparoscopic hysterectomy, and mini-laparoscopy [defined as port sites not exceeding 3 mm]) with open abdominal surgery reported the following [3]:

●Improved outcomes – For laparoscopic hysterectomy compared with abdominal hysterectomy:

•Quicker return to normal activities by over 15 days [3]

•Shorter hospital admission by one to three days, depending on type of laparoscopic hysterectomy [3,17]

•Reduced risk of wound or abdominal wall infection by approximately 70 percent [3]

•Lower increased risk of venous thromboembolism with every 60-minute increase in operative time [18]

●Worsened outcomes – For laparoscopic hysterectomy compared with abdominal hysterectomy:

•Twofold increased risk of urinary tract (bladder or ureter) injuries [3,19]

•Approximately 30 minute longer operative time

Patient populations and contraindications — Consensus guidelines regarding optimal patient population(s) for laparoscopic hysterectomy are not available. For enlarged uteri, no studies have compared the use of laparoscopic hysterectomy with morcellation, vaginal hysterectomy with morcellation, and open abdominal surgery.

●Potential indications – Laparoscopic hysterectomy is particularly useful in patients with limited vaginal access, a fixed immobile uterus, or who desire supracervical hysterectomy. As the laparoscopic approach provides direct visualization of the intraperitoneal cavity compared with transvaginal surgery, the laparoscopic approach may be particularly helpful for individuals with documented endometriosis, chronic pelvic pain, pelvic adhesive disease (known or suspected), and benign pathology that requires removal (eg, adnexal mass or cyst).

●Contraindications – When planning for laparoscopic hysterectomy, the surgeon must confirm that laparoscopy is technically possible [2]. The American Association of Gynecologic Laparoscopists has defined contraindications to laparoscopic hysterectomy as:

•Significant cardiopulmonary disease with intolerance to increased intraperitoneal pressure

•Suspicion of malignancy when morcellation would be required

Robot-assisted laparoscopy — Robot-assisted laparoscopy, a variation on the conventional laparoscopic technique, has been used for hysterectomy but has not been reported to improve surgical outcomes compared with traditional laparoscopy [3,20-28]. As such, conventional laparoscopic hysterectomy is preferred to robot-assisted hysterectomy when the vaginal approach is not feasible.

●Potential benefits – As robot-assisted laparoscopy provides improved visualization with three-dimensional imaging, better mechanics, improved ergonomics, and an easier and faster learning curve for many surgeons, and has similar outcomes compared with traditional laparoscopy, it may be helpful for avoiding open abdominal hysterectomy or in select populations, such as the very obese or those with severe pelvic adhesive disease [27,29-31]. Subgroups of patients who clearly benefit from the robot-assisted approach to hysterectomy have not yet been defined [31].

●Disadvantages – Disadvantages include the need for additional surgical training, loss of haptic feedback, and cost. In addition to the cost of the system, the surgical instruments that attach to the robotic arms must be replaced after every 10 uses. (See "Robot-assisted laparoscopy", section on 'Robot-assisted versus other surgical approaches'.)

●Outcomes – Surgical outcomes are similar for traditional laparoscopy and robot-assisted laparoscopy when used for hysterectomy [3,20-24,27]. When comparisons are made between robot-assisted laparoscopic hysterectomy and open abdominal hysterectomy, the open approach may be associated with a higher incidence of complications [27].

Single-port — While traditional laparoscopic hysterectomy remains the technique of choice if vaginal hysterectomy is not feasible, single-port laparoscopy is a variant of the conventional laparoscopic technique. Compared with traditional laparoscopy for hysterectomy, single-port surgery can be more technically challenging to perform. One potential advantage is that similar instrumentation can also be used transvaginally to accomplish "natural orifice" transvaginal hysterectomy [32]. (See 'Vaginal hysterectomy' above.)

Compared with traditional laparoscopy, studies of the single-port laparoscopy have reported:

●Surgical outcomes – A 2015 meta-analysis of randomized trials found that single-port laparoscopy offered no advantages over traditional laparoscopic techniques [3]. Continued development and use of single-port systems may identify patient groups who benefit from this approach. As the operative outcomes are not worse for single-port laparoscopy compared with traditional laparoscopy, single-port laparoscopy is an option for individuals who prioritize a single incision for cosmesis or other reasons. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Single-incision laparoscopic surgery'.)

●Possible reduction in postoperative pain – A randomized trial comparing single-port with traditional laparoscopic hysterectomy reported that single-port surgery was associated with reduced pain scores at 24 and 48 hours and lower narcotic use, but it is not known if these differences were clinically important [33].

Abdominal hysterectomy — Abdominal hysterectomy is the default procedure when vaginal or laparoscopic hysterectomy cannot manage the patient's clinical situation or when facilities cannot support a specific procedure [2,4]. (See "Hysterectomy: Abdominal (open) route".)

FACTORS THAT INFLUENCE SURGICAL ROUTE — Characteristics proposed as selection criteria for determining the feasibility of a minimally invasive hysterectomy include uterine size, mobility, accessibility, and uterine pathology (not including adnexal pathology or suspected adhesions) (algorithm 1) [34-36].

Uterus size, shape, and accessibility

●Uterus size – Although the upper limit of uterine size for vaginal hysterectomy has not been established, many surgeons would consider 16-week size as a reasonable and practical upper limit [37]. When vaginal access is adequate and the uterus is enlarged, vaginal hysterectomy is accomplished using uterine size reduction techniques such as wedge morcellation, uterine bisection, and intramyometrial coring.

•Vaginal versus abdominal routes – A randomized trial comparing vaginal and abdominal hysterectomy for 119 women with enlarged uteri (200 to 1300 grams) reported decreased operating time, febrile morbidity, postoperative narcotic use, and hospital stay for the vaginal hysterectomy group [38].

•Vaginal versus laparoscopic routes – A retrospective cohort study comparing vaginal (n = 1870) with laparoscopic (n = 3740) total hysterectomy for patients with enlarged uteri (weight >250 grams) reported similar major complication rates between the groups (4.3 versus 5.3, respectively) [39]. Intraoperative cystotomies were more common with vaginal surgery while ureteral injuries were more common with laparoscopic surgery (cystotomy 0.8 versus 0.3 percent, ureteral injury 0.2 versus 1.2 percent), which is consistent with those surgical approaches. Vaginal surgery was associated with a lower probability of operating time exceeding 2.5 hours.

For experienced surgeons, uterus size is less of a barrier for minimally invasive hysterectomy. While uterus weight is an independent risk factor for posthysterectomy complications, abdominal hysterectomy has higher odds of any complication compared with laparoscopic hysterectomy, even in women with markedly enlarged uteri [40]. Uterine weight alone is not an appropriate indication for abdominal hysterectomy as large uteri can be safely removed laparoscopically.

●Uterus shape – We believe uterus shape is often more important than actual size in considering vaginal hysterectomy. Before beginning any morcellation procedure, the uterine vessels are ligated bilaterally, and the peritoneal cavity is entered both anteriorly and posteriorly. If the cervix or lower uterine segment is enlarged or contains fibroids that prevent uterine artery ligation or entry into the peritoneal cavity, then the procedure is not performed vaginally. In contrast, if the lower uterine segment is accessible surgically, then even very large uteri (up to 20-week size) can be removed transvaginally by an appropriately skilled surgeon.

●Accessibility of the uterus – If the vaginal aperture is adequate to allow division of the uterosacral and cardinal ligaments, uterine mobility is often adequate to allow completion of vaginal hysterectomy, even if there is minimal uterine descent [41]. Historically, a narrow pubic arch (less than 90 degrees), a narrow vagina, an undescended immobile uterus, and nulliparity were proposed as contraindications for vaginal hysterectomy, but this thinking no longer applies. In a retrospective review of 300 individuals without prior vaginal delivery who underwent hysterectomy, 92 percent of the planned vaginal hysterectomies were completed by the vaginal route [42]. Of note, nearly 76 percent of cases were planned as vaginal hysterectomies.

Additional pathology or need for abdominal exploration

●Extrauterine pathology – Disease outside the uterus, such as adnexal pathology, obliterated cul-de-sac, endometriosis, or pelvic adhesions, may prevent vaginal hysterectomy. Laparoscopy can be useful in these cases to visualize pelvic anatomy and pathology and directly inform the choice of hysterectomy route. In a study of 46 individuals who had been advised to have an abdominal hysterectomy, findings at intraoperative laparoscopy allowed 91 percent of the patients to have a vaginal hysterectomy [43].

●Need to evaluate the intrabdominal cavity – Vaginal hysterectomy does not allow thorough examination of the abdomen. When this is required, a laparoscopic approach is appropriate. (See "Hysterectomy: Laparoscopic".)

Patient characteristics

●Prior cesarean delivery or pelvic surgery – While a history of previous pelvic surgery raises concerns about lower uterine segment scarring, resultant bladder trauma, excessive bleeding, and potential unsuccessful vaginal route, prior cesarean delivery is not a contraindication to vaginal hysterectomy. Surgical risk, particularly for blood transfusion, may be increased with increasing number of cesarean deliveries, but overall risk of severe surgical complications does not appear to be increased. Supporting data include:

•A registry-based cohort study from Denmark (n = 7685 individuals) reported the peri- and postoperative complications at hysterectomy were more frequent in patients with previous cesarean deliveries, with adjusted odds ratios (aORs) of 1.16 (95% CI 0.98-1.37) for one cesarean delivery and 1.30 (95% CI 1.02-1.65) for two or more cesarean deliveries [44]. Administration of blood transfusion was almost twice as frequent after two or more cesarean deliveries.

•A retrospective review of 742 vaginal hysterectomies performed at an academic medical center also noted prior cesarean delivery increased the risk of blood transfusion at the time of vaginal hysterectomy but reported similar rates of grades 2 to 3 Clavien-Dindo complications among patients with and without prior cesarean delivery (table 2) [45].

●Nulliparity – Nulliparity is not a contraindication to vaginal hysterectomy; patients who are nulliparous or who have not delivered vaginally can safely undergo vaginal hysterectomy [42]. A prospective study comparing vaginal hysterectomy outcomes in 52 nulliparous and 293 primiparous or multiparous women reported nulliparity was associated with longer mean operative times (95 versus 80 minutes), higher overall complication rates (13 versus 4 percent), and increased hemorrhage rates (7.7 versus 1.7 percent) [46]. Nevertheless, vaginal hysterectomy was successfully performed in 50 of the 52 nulliparous and 292 of the 293 parous patients. This suggests that nulliparous women are candidates for vaginal hysterectomy.

●Obesity – Obesity is not a contraindication to vaginal hysterectomy and thus is the preferred route for hysterectomy if other criteria for vaginal surgery are met [47-49].

•Compared with laparoscopy – Laparoscopic hysterectomy is selected when the vaginal route is not possible; complication rates are similar for patients with and without obesity who undergo laparoscopic hysterectomy [50]. For individuals with obesity who undergo laparoscopic or robot-assisted laparoscopic hysterectomy, the risk of conversion to open surgery appears to be increased and in proportion to the degree of obesity [51,52].

•Compared with open abdominal surgery – Abdominal hysterectomy in patients with obesity has been reported as having a five times higher risk of wound dehiscence, five times higher risk of wound infection, and 89 percent increased risk of sepsis as compared with abdominal hysterectomy in patients with normal body mass index [53].

●Patient preoperative ASA classification– In a National Surgical Quality Improvement Program database study, 117,919 patients who underwent either minimally invasive hysterectomy (vaginal, laparoscopic, robotic) or abdominal hysterectomy were compared. Patients with increased preoperative risk as defined by a high ASA classification were less likely to undergo a hysterectomy using a minimally invasive route for benign indications.

●Patient preference – An informed patient may have a preference for the hysterectomy route. After consideration of the advantages and disadvantages of each type of hysterectomy, the surgeon can then include the patient in the discussion and arrive at the optimal surgical route for her disease and circumstances.

Need for additional procedures or supracervical hysterectomy

Prophylactic oophorectomy or salpingectomy — Briefly, the decision to perform prophylactic oophorectomy and/or salpingectomy at hysterectomy is based on patient preference, age, and medical risk factors [54]. The use of laparoscopic-assisted vaginal hysterectomy or total laparoscopic hysterectomy purely to facilitate tubal or ovarian removal is not supported by convincing evidence [55,56]. From a practical perspective, the rate of prophylactic oophorectomy is 4 to 12 times higher with abdominal or laparoscopic routes compared with vaginal surgery, which may reflect challenges inherent in performing oophorectomy by the vaginal route (eg, an ovary that is scarred to the pelvic sidewall and cannot be mobilized or a short infundibulopelvic ligament both limit surgical access to the ovary), reduced surgeon experience with vaginal oophorectomy, or patient preferences [57,58].

●Vaginal salpingo-oophorectomy success rates – In a study of 258 patients undergoing vaginal hysterectomy, although 56 percent had at least one relative contraindication to concurrent salpingo-oophorectomy, successful removal was achieved in 87 percent of patients [59]. Thus, patients who are candidates for vaginal hysterectomy and who desire prophylactic oophorectomy based on their risk profile are counseled that vaginal oophorectomy is possible in a majority of cases but that laparoscopy or minilaparotomy may be necessary to complete the oophorectomy.

●Relative contraindications to vaginal salpingo-oophorectomy – Relative contraindications to concurrent salpingectomy or oophorectomy at the time of vaginal hysterectomy may include lack of pelvic organ descent, an enlarged uterus, previous cesarean delivery, known pelvic adhesions, and known adnexal pathologic conditions.

The risks and benefits of elective oophorectomy and/or salpingectomy at the time of hysterectomy are discussed in detail elsewhere.

●(See "Elective oophorectomy or ovarian conservation at the time of hysterectomy".)

●(See "Risk-reducing salpingo-oophorectomy in patients at high risk of epithelial ovarian and fallopian tube cancer".)

Pelvic organ prolapse — Hysterectomy is often performed at the time of surgical repair of pelvic organ prolapse (POP). However, this varies in part by surgical route (vaginal or abdominal) and use of synthetic materials for repair. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant hysterectomy'.)

Supracervical (subtotal) hysterectomy — In general, the decision to remove the cervix with the uterine corpus (ie, total hysterectomy) or just the corpus (ie, supracervical or subtotal hysterectomy) is mainly driven by patient preference to retain the cervix. The only absolute contraindication to supracervical (subtotal) hysterectomy is malignant or premalignant condition of the uterine corpus or cervix. The potential advantage of shorter operative time with supracervical hysterectomy is small (about 11 minutes for open abdominal surgery) and must be balanced against the potential need for future treatment of cervical cancer (0.05 to 0.27 percent) or cervical bleeding [60]. (See "Hysterectomy (benign indications): Patient-important issues and surgical complications", section on 'Risk of occult malignancy'.)

●Comparison of surgical outcomes for supracervical and total hysterectomy

•A 2012 systematic review of nine randomized trials (n = 1553) comparing total versus supracervical hysterectomy found no difference between groups in major outcomes such as urinary, bowel, or sexual function; recovery from surgery; complications; readmission rate; and transfusion [61]. Major disadvantages of the supracervical procedure were continued need for cancer screening and cyclic vaginal bleeding, which occurred in 7 to 20 percent of patients with supracervical hysterectomy compared with 1 to 3 percent of patients with total hysterectomy. In addition, approximately 2 percent of patients subsequently needed trachelectomy. The patients in these trials were followed from two to nine years.

•A subsequent study of individuals from a previous randomized trial reported on outcomes 14 years after surgery. Similarly, there were no differences in urinary incontinence, POP, and prolapse symptoms between women undergoing supracervical or total hysterectomy [62]. One hundred of the original 304 women from the original trial participated in the follow-up study.

●Patients who may benefit from supracervical hysterectomy – Circumstances in which supracervical hysterectomy is performed include before some types of sacrocolpopexy and for patients who prefer this option for personal or sexual reasons. However, data regarding the impact of total versus supracervical hysterectomy on sexual function are mixed, in part because of different indications for the procedures, impact of concomitant oophorectomy, varying outcomes measured, and use of retrospective data with small numbers of included patients [63-66]. While a patient may prefer supracervical hysterectomy, the data do not suggest improved sexual function with retention of the cervix. (See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Abdominal sacrocolpopexy'.)

●Patients who may benefit from total hysterectomy – While not absolute contraindications to supracervical hysterectomy, individuals with endometriosis and chronic pain syndromes may benefit from total removal of the uterus. However, more data are needed before definitive recommendations can be made.

•Endometriosis – Supracervical hysterectomy performed for endometriosis, but not adenomyosis, has been associated with increased risk of future trachelectomy [67,68]. In a retrospective case-control study of 17 women who underwent supracervical hysterectomy, women with a history of endometriosis had an approximately sixfold increased risk of subsequent trachelectomy compared with those without [67].

•Chronic pain syndromes – In a retrospective cohort study of cervix specimens from 35 individuals, cervices from those with pain syndromes had more nerve fibers per high power field than cervices of those without pain or control women, a trend which was also seen in patients with endometriosis [69]. This small study provides indirect data that total hysterectomy may be beneficial in individuals with chronic pelvic pain as their indication for hysterectomy.

Use of a surgical decision support tool — Given improved patient outcomes with vaginal hysterectomy compared with other routes, decision support tools have been developed to encourage surgeons to pursue vaginal surgery as their first-line route and then guide them to other approaches based on specific criteria. Supporting data include:

●One United States academic center reported that use of a decision-tree algorithm triaged the majority of patients to total vaginal hysterectomy (71 percent) and more than 99 percent of the total attempted vaginal hysterectomies were completed by that route [70].

•Selection of surgical route was primarily based on uterus size, mobility, and location, as well as vaginal caliber and prior pelvic surgery.

•Exclusion criteria for vaginal surgery included adnexal disease, planned-for additional incontinence or prolapse procedures (other than pure uterine), cervical cancer beyond stage 1A1, uterine or müllerian anomalies, and malignancy (confirmed or suspected).

●In a South African academic medical center, implementation of a clinical decision-tree algorithm and standardized surgical technique increased rates of vaginal hysterectomy (from 9.8 percent to 48.2 percent) and reduced rates of abdominal hysterectomy (from 91.2 to 51.6 percent) [71]. The ratio of vaginal hysterectomy to abdominal hysterectomy increased from 1:9 in 2001 to 1:1 by 2014. None of the vaginal surgeries required conversion to an abdominal route.

Surgeon volume — Surgeon volume is inversely related to patient outcomes and complication rates [72-77]. Experienced high-volume surgeons at high-volume hospitals have less blood loss, fewer adverse events, and lower costs. In addition, high-volume surgeons are more likely to use minimally invasive routes of hysterectomy [75].

Cost considerations

●By surgical route – Cost-analysis trials consistently demonstrate that vaginal hysterectomy is the most cost-effective route [78-80] and robot-assisted hysterectomy is the least cost-effective route [80,81]. Laparoscopic hysterectomy can be cost-effective relative to abdominal procedure [82], but the difference varies among surgeons, health systems, countries, and viewpoints (societal versus institutional) [79,83].

●Drivers of cost – The main cost determinants are the length of hospital stay, the length of operating room time, and the use of disposable surgical devices [78]. Local initiatives and cost-awareness campaigns may be associated with reduction in cost of surgery for laparoscopic hysterectomy [84].

●Robot-assisted procedures – Some experts have stated that, based on the available data, a scenario in which robot-assisted hysterectomy is cost-effective is unlikely [81]. One challenge to assessing cost-effectiveness is that cost can be calculated as the cost of all the equipment (including the purchase of the robot system) or as the cost of equipment used per case (ie, assume the robot system is a preexisting investment). In general, robot-assisted laparoscopic hysterectomy is more costly than conventional laparoscopic technique [20-22,85,86]. (See "Robot-assisted laparoscopy", section on 'Are surgical robots cost-effective?'.)

ADDITIONAL SURGICAL PLANNING — An overview of issues pertaining to preoperative preparation and assessment, including antibiotic administration and prevent of thromboembolic events, can be found separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)

Enhanced recovery after surgery — Enhanced recovery after surgery (ERAS) programs are perioperative protocols of evidence-based interventions that have been grouped together with the goals of speeding functional recovery and improving postoperative outcomes. ERAS programs typically include multidisciplinary and multimodal interventions aimed at minimizing the physiologic changes associated with surgery. Patient benefits associated with ERAS include reduction in postoperative opioid use and length of stay. (See "Enhanced recovery after gynecologic surgery: Components and implementation".)

Patient education

●Rationale for hysterectomy – The reason for the hysterectomy, risks and benefits of the procedure, alternatives, and expectations for outcome should be discussed with the patient in detail. Since a number of the indications for hysterectomy are based more upon opinion than evidence from well-designed studies, informed consent with thorough exploration of patient preferences and expectations is particularly important [87]. In the absence of a life-threatening emergency (eg, uterine hemorrhage), the decision to proceed with hysterectomy is made mutually by the patient and her clinician based upon her functional impairment, childbearing plans, response to medical therapy, discussion of alternatives, and perception that the risks of the procedure are outweighed by the expected benefits.

●Postoperative expectations – Patients should be provided with clear information about what to expect during their hospitalization and regarding return to normal activities. Education during the preoperative office visits will enhance the patient's acceptance and compliance during the immediate postoperative period and may help to shorten hospital stay.

Informed consent — Informed consent for route of hysterectomy is a process. The route and type of hysterectomy is discussed in detail, including the advantages and disadvantages of each option and the surgeon's recommendation. The reason for the hysterectomy, risks and benefits of the procedure, alternatives, and expectations for outcome are discussed. Issues regarding total versus supracervical (subtotal) hysterectomy, and whether adnexal surgery is indicated, are discussed. Risk of occult malignancy that may require further surgical or medical therapy is included on the consent form. The possibility of conversion from a laparoscopic or vaginal approach to laparotomy, if necessary, is also reviewed.

●(See "Informed procedural consent", section on 'Informed decision-making'.)

●(See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Informed consent and patient expectations'.)

SUMMARY AND RECOMMENDATIONS

●Summary – For individuals with benign gynecologic disease undergoing hysterectomy, vaginal hysterectomy is the preferred approach when technically possible because of its documented advantages and relatively lower complication rates (algorithm 1). If a vaginal hysterectomy is not feasible, then laparoscopic hysterectomy is performed. Laparoscopy is preferred to laparotomy because of decreased morbidity and mortality. Hysterectomy by laparotomy is reserved for all other cases. The role of robot-assisted laparoscopy for hysterectomy is under evaluation. This approach is in accord with national and international groups. (See 'Route of hysterectomy for benign disease' above.)

•Vaginal approach preferred when possible – For individuals in whom all routes of hysterectomy are technically feasible, we recommend a vaginal approach (Grade 1B). Compared with other routes of hysterectomy, it is less invasive, more cosmetic, and associated with fewer complications, shorter hospital admission, and lower cost. Individuals who have larger uteri, adnexal pathology, extrauterine disease, advanced endometriosis, or who desire definitive oophorectomy may require laparoscopic assistance at hysterectomy to complete the surgery. (See 'Vaginal hysterectomy' above.)

•Laparoscopy if vaginal surgery not feasible – For individuals in whom vaginal hysterectomy is contraindicated or not technically possible, we suggest conventional laparoscopic hysterectomy rather than abdominal hysterectomy (Grade 2B). Robot-assisted laparoscopy and single-port laparoscopy do not have improved outcomes compared with conventional laparoscopy but may be considered in select cases. (See 'Laparoscopic hysterectomy' above.)

•Total rather than supracervical hysterectomy – For individuals undergoing hysterectomy, we suggest performing total hysterectomy rather than supracervical hysterectomy (Grade 2B). There are no proven medical or surgical benefits of performing supracervical (subtotal) hysterectomy if the cervix can be easily removed with the corpus. However, some individuals may choose this option after appropriate counseling of its benefits and risks. Those who retain their cervix continue with cervical cancer screening according to guidelines. (See 'Supracervical (subtotal) hysterectomy' above.)

●Additional surgical factors for consideration – Additional factors that influence the route of hysterectomy for benign indications include:

•Surgical indications and patient factors – Selection of surgical approach for hysterectomy for benign disease is impacted by the surgical indications and related issues of uterine size and pathology, pelvic anatomy, and vaginal access. In general, factors such as prior cesarean delivery, nulliparity, and obesity do not influence the route of hysterectomy.

-(See 'Uterus size, shape, and accessibility' above.)

-(See 'Patient characteristics' above.)

•Potential pathology and/or need for additional surgery – Potential presence of uterine pathology, need for abdominal exploration, or need for additional surgery may increase the benefits of one approach over the others. (See 'Additional pathology or need for abdominal exploration' above and 'Need for additional procedures or supracervical hysterectomy' above.)

●Additional surgical planning – Additional considerations include protocols for enhanced recovery after surgery (ERAS), patient education, and informed consent. (See 'Additional surgical planning' above.)