Your Hysterectomy – Retain or remove the cervix?
The great debate roars. You are due for a hysterectomy for a non-cancerous or non pre-cancerous condition, and calculating whether or not to have your cervix removed? Welcome to the world of some 600,000 hysterectomies per year in the United States. History reveals. The time tried Vaginal Hysterectomies always include removal of the cervix. Up until World War II the universal abdominal approach was the Supracervical Hysterectomy, with the above (supra) non-removal of the cervix. In the 1950’s advances in antibiotics, blood banking, and anesthesia, and concerns for cervical cancer, the Total Abdominal Hysterectomy, with removal of the cervix, became the standard of practice. In 1988 Dr. Harry Reich from Pennsylvania advocated the first laparoscopic hysterectomy. This minimally invasive procedure grew in popularity and rapidly evolved. The challenge at the time was securing the major blood supplying vessels to the uterus, the uterine arteries. Playing it safe, Dr. Reich brilliantly suggested surgically dissecting the first half of the operation through the abdominal scope (laparoscope), and the second half with the major vessel ligation (uterine arteries) through the vagina, with removal of the cervix. Securing these vessels through the vagina was a time proven method of which gynecologic surgeons were most familiar. Thus the Laparoscopic Assisted Vaginal Hysterectomy (LAVH) was born. With advancing technology and better instrumentation, this was eventually forwarded to complete the entire procedure from the abdomen, through the scope. The advent of today’s Laparoscopic Supracervical Hysterectomy (LSCH), and the Laparoscopic Hysterectomy (LH) with removal of the cervix.
Upside and downside. On the positive end the retained cervix will preserve the support of the bladder, and upper vagina. Vaginal length will best be preserved without scarring. On the downside, some have complained of vaginal shortening after the cervix is removed, secondary to vaginal cuff closure and scarring, with resultant dyspareunia (pain with intercourse). Studies have essentially supported there is no change in sexual sensation and/or orgasmic ability with or without the cervix. Leaving the cervix will require continuation of regular Pap smears.
With all the debate, The Am College of Ob Gyn (ACOG) in their November 2009 Committee Opinion stated, “Vaginal hysterectomy is the approach of choice.” Many believe this opinion is rapidly becoming outdated. ACOG went on to further state, “Laparoscopic hysterectomy is an alternative to abdominal hysterectomy if a vaginal hysterectomy is not indicated or feasible.” My belief is the non removal of the cervix in the absence of pathology will become the laparoscopic hysterectomy of choice. The more invasive abdominal hysterectomy will be replaced by laparoscopic surgery. This will defeat the popular vaginal hysterectomy with the removal of the cervix in non cancerous or precancerous states. Our current young generation will see less and less cervical cancer with the advent of the Human Papilloma Virus (HPV) Vaccine injections. My thought, save your cervix when planning a hysterectomy in the absence of a cancerous or a pre-cancerous state. Always consult your surgeon before making a final decision.