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Journal of Medicine and Biomedical Research
College of Medical Sciences, University of Benin
ISSN: 1596-6941
Vol. 4, Num. 1, 2005, pp. 5-8
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Untitled Document
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
- Lepine LA, Hillis SD, Marchbanks PA, et al, Hysterectomy
surveillance -United States, 1980-1993. Mor Mortal Wkly Rep CDC Surveill
Summ 1997; 46: 1-14.
- Thakar R, Ayers s, Clarkson P, Stanton S, Manyonda I. Outcomes
after Total versus Subtotal Abdominal Hysterectomy. N Engl J Med. 2002;
347:1318-1325.
- Hasson HM. Cervical removal at hysterectomy for
benign disease. J Repro Med. 1993; 38: 781-90.
- Kilkku P, Gronroos M, Hirvonen T, Rauramo L. Supravaginal
uterine amputation vs hysterectomy: effects on libido and orgasm. Acta
Obstet Gynaecol Scand. 1983;62:147-153
- DeLancey JL. Anatomic aspects of vaginal eversion
after hysterectomy. Am J Obstet Gynaecol. 1992; 166:1717-26.
- Dennerstein L, Wood C, Burrows GD. Sexual response
following hysterectomy and oophorectomy. . Obstet. Gynaecol 1997; 49: 92-96.
- Howkins J, Hudson C.N. Abdominal hysterectomy for
benign conditions. In; Shaw's textbook of Operative
Gynaeco-logy. 5th edition. Howkins J & Hudson CN (eds).
Churchill Livingstone, 1983; Pp 126-140.
- Ursular S. A look at cervical cancer. Medscape
Ob/Gyn & Women's
Health 2003. 8 (1): Pp 1-8.
- Gharoro EP, Abedi HO, Okpere EE. Cancer of the cervix.
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