Journal of Medicine and Biomedical Research College of Medical Sciences, University of Benin ISSN: 1596-6941 Vol. 4, Num. 1, 2005, pp. 5-8

Journal of Medicine and Biomedical Research, Vol. 4, No. 1, June 2005, pp. 5-8

Editorial

Hysterectomy for reproductive health care in low-resource settings

¹Omo-Aghoja LO, ²Okonofua FE

¹Department of Obstetrics and Gynaecology, College of Health Sciences, Delta State University, Abraka, and ²Department of Obstetrics and Gynaecology, College of Medical Sciences, University of Benin, Benin City, Nigeria.

Code Number: jm05001

Hysterectomy is a very common gynaeco-logical operation¹. This may be total or subtotal (supracervical or partial). A subtotal hysterectomy is the removal of the uterus while leaving the cervix in place, while a total hysterectomy is the removal of the entire uterus and the cervix². The extent of the surgery is largely determined by the indication for the operation and the skill of the operator. Total hysterectomy has implications for women's reproductive health, as the removal of the uterus has the potential for reducing the incidence of genital tract malignancies, specifically those of endometrium and cervix.

Before surgeons learned to safely remove the cervix, the tendency was to leave it in place during a hysterectomy. In particular, the subtotal technique was frequently used as a method of treatment for certain benign uterine diseases, such as the removal of a uterus containing leiyomyomata³. It was also and is still largely the modality of treatment in dire obstetric emergencies such as uncontrollable postpartum haemorrhage and ruptured uterus when considerable speed is needed to salvage the patient⁴. In the 1940s, 95% of hysterectomies performed in the United States were subtotal³.

In the late 1940s and the 1950s, improve-ments in surgical technique (better anaesthe-sia, availability of antibiotics and blood products, as well as a greater number of trained gynaecologists) and a desire to prevent cervical cancer as a result of reports that cancer of the cervical stump occurred in 1% to 2% of patients undergoing hysterectomy, resulted in the adoption of the routine removal of the cervix with the rest of the uterus at hysterectomy³. Thus, complete hysterectomy became the method of choice.

Much recently, there has been a resur-gence of interest in leaving the cervix at the time of hysterectomy². This progressively increasing consideration for subtotal hysterectomy in recent years is premised on several reasons as enunciated below³. In the first place, it is thought that conservation of the cervix minimizes neurologic and anatomical disruption and therefore helps to reduce potential adverse effects on the bladder, bowel, and sexual function. For example, it has been argued that orgasm is better if the cervix is left behind⁴. Additionally, it has been hypothesized that subtotal hysterectomy decreases the incidence of post-hysterectomy prolapse of the vaginal vault by preserving connective tissue support of the upper vagina⁵. Also, in the mid-1950s, cytological screening for cervical neoplasia (Papanicolaou smear) became accepted. Its availability, coupled with a corresponding public education program, resulted in a 27% reduction in mortality due to reproductive organ cancers³. This implies that morbidity and mortality from cervical cancer can be minimized by adherence to recommended Pap smear screening guidelines, without the need to remove the cervix. Shorter hospital stay and less febrile morbidity are other points of argument in favour of sub-total hysterectomy.

However, a number of scientific studies seem to invalidate the above arguments and suggest that subtotal hysterectomy confers no advantage over total abdominal hysterectomy². Reports of various studies² found no difference in any of the measures of urinary or bowel functions between the two operations before or after surgery or overtime. With regards to sexuality, a few studies have suggested that hysterectomy adversely affects sexual performance⁶. By contrast, a larger number of studies ² found no differences between the two operations with regard to frequency of intercourse or orgasm, while there was similar rate of reduction in the incidence of deep dyspareunia in both treatment groups. Similarly, the argument that subtotal hysterectomy may prevent vaginal vault prolapse is nebulous. Howkins and Hudson (1983)⁷ documented that the incidence of vault prolapse is increased following subtotal hysterectomy, the retained cervix acting as a plunger to form the apex of the vaginal intussusception. Thacker et al (2002)² seem to have reinforced this assertion when in their randomized double blind trial, they demonstrated cervical prolapse in two patients who underwent subtotal hysterec-tomy, but none in those who had total hysterectomy. Additionally, uterine prolapse is a common indication for hysterectomy with the supporting structures which are frequently damaged by child birth repaired during hysterectomy. There are no good studies comparing vaginal prolapse with or without removing the cervix.

There is one remaining strong argument in favour of sub-total hysterectomy - this is that the subtotal operation in a difficult hysterectomy is less morbid to the urinary tract, and that the damage to the ureters and bladder in the hands of a less experienced operator recommends the adoption of the sub-total procedure. However, to counter this argument, it must be said that hysterectomy is not an operation for the inexperienced surgeon any more than gastrectomy is, and that it should be our aim always to train competent pelvic surgeons in whose hands the total operation is safe. Although a ureteric fistula is reprehensible and regrettable, it is rarely as lethal as a stump cervical cancer.

Some authors have argued that another major reason for the original shift from sub-total to total hysterectomy have been invalidated by the general use of cervical cancer screening by cytologic smear. While this reasoning seems scientifically plausible and possibly applicable in well developed societies where there are well organized screening facilities, the same cannot be said for low resource countries with poorly developed cervical cancer screening facilities. Indeed, it is well known that cervical cancer screening is less likely to reduce morbidity and mortality from this disease to the same extent as removal of the cervix, given incomplete compliance with screening recommendations and imperfect laboratory techniques. This clearly shows that the risk of cervical cancer will only be eliminated if a total hysterectomy is performed. From the foregoing, and despite formidable literature inspired by the controversy of total versus subtotal hysterectomy, one indisputable fact is that cancer of the residual stump is a genuine entity, with an incidence worldwide of between 1-2% ³.

Cancer of the residual cervix is a particularly lethal disease in that the removal of the uterine body encourages a more rapid and direct spread to the bladder and, sometimes, to the rectum. Radiation treatment of stump cancer is prejudiced by the absence of uterine cavity in which to place the main intra-uterine tube, and the radiotherapist is obliged to rely on vaginal applicators or supervoltage radiation. The case for the availability of good screening methods is further weakened by the fact that adenocarcinoma of the cervix is increasing in frequency, and can be fatal. In addition, there are now reports of having to go back and remove the cervix after a supracervical hysterectomy because of bleeding or other problems.

All over the world, particularly in low income countries carcinoma of the cervix continues to be a major public health concern. Globally, cancer of the cervix is the second most common malignancy and the leading cause of death amongst women in low income countries and accounts for 80% of the 231,000 deaths worldwide annually⁸. Report from a Nigerian tertiary hospital in 2001⁹ indicated that cancer of the cervix accounted for 4.35% of all gynaecological admissions and 74.6% of all gynaecological malignancies. It also revealed that 75% of the patients presented in advanced stages and this coupled with the lack of organized screening programmes for detection of the pre-clinical stages in many low income countries, largely account for the high mortality rate attributable to cervical pathology.

Clearly, the foregoing analysis indicates that there are no differences in outcomes for both total and subtotal hysterectomy. We therefore strongly posit that the argument for sub-total hysterectomy in low resource settings is not supported by the available data.

In sum, there can be no doubt that total hysterectomy is one of the most important ways of preventing and decreasing the incidence of female genital malignancies, specifically cervical cancer in low-income countries. In view of the potentially beneficial effects of reducing the high rates of female morbidity and mortality in Africa, it is no longer morally and ethically acceptable that women are denied the benefits of total hysterectomy.

Further research is justified, especially in low resource settings. However, at the moment, we conclude that a deliberate policy of leaving the cervix behind at the time of hysterectomy cannot be justified in low income countries, and that the objective should always be to remove the cervix at hysterectomies whenever possible. Sub-total hysterectomy should be reserved for extremely moribund conditions, when the skills of the gynaecological surgeon does not permit a full hysterectomy, and should be done only to preserve the integrity of adjacent organs such as the ureters, and to reduce the operative time in moribund patients. With increasingly better training of gynaecological surgeons, this indeed, should be a very rare necessity. The removal of the cervix at the time of indicated hysterectomy in order to prevent future morbidity and mortality to women is an important reproductive health goal that should be pursued as a way to enhance women's health in low resource settings.

References

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