Hysterectomy

Types of Hysterectomy

By Extent of Uterine Removal

By Route of Access

1. Vaginal hysterectomy (VH) - the preferred route unless contraindicated
2. Abdominal hysterectomy (total abdominal hysterectomy, TAH) - open laparotomy via low transverse (Pfannenstiel) or vertical midline incision
3. Laparoscopic hysterectomy (LH) - includes laparoscopic-assisted vaginal hysterectomy (LAVH), total laparoscopic hysterectomy (TLH), and laparoscopic supracervical hysterectomy (LSH)
4. Robotic-assisted laparoscopic hysterectomy - uses the da Vinci system; no proven advantage over conventional LH in randomized trials

Indications

• Intractable dysmenorrhea / chronic pelvic pain refractory to medical therapy
• Cervical intraepithelial neoplasia (CIN)
• Obstetric emergencies (postpartum hemorrhage, uterine rupture)
• Pelvic inflammatory disease (PID) with abscess not responding to treatment
• Adenomyosis
• Pelvic organ prolapse

Surgical Access - Choice and Comparison

"Adopting published guidelines for choosing the route of hysterectomy increased the proportion performed vaginally to over 90% and reduced the ratio of abdominal to vaginal hysterectomy from 3:1 to 1:11."

• Berek & Novak's Gynecology, p. 1418

• Cardiopulmonary disease precluding pneumoperitoneum
• Suspected uterine malignancy requiring morcellation avoidance
• Severely distorted anatomy not amenable to laparoscopic/vaginal approach
• No access to surgeons skilled in minimally invasive techniques

Surgical Technique

Total Abdominal Hysterectomy (TAH) - Key Steps

1. Transect round ligaments bilaterally
2. Incise anterior and posterior broad ligament
3. Develop bladder flap - dissect bladder off the lower uterine segment/cervix
4. Divide ovarian vessels (infundibulopelvic ligament) if bilateral salpingo-oophorectomy (BSO) is planned; or divide uteroovarian vessels to preserve ovaries
5. Skeletonize and ligate uterine arteries at the level of the internal cervical os (clamp, cut, suture-ligate with delayed absorbable suture)
6. Serial clamping and ligation of cardinal and uterosacral ligaments
7. Colpotomy - circumferential incision of the vagina just below the cervix
8. Close vaginal cuff - lateral angle sutures incorporate uterosacral ligaments for apical support

Vaginal Hysterectomy - Key Steps

1. Circumferential colpotomy around cervix
2. Enter posterior cul-de-sac; clamp/ligate uterosacral ligaments
3. Dissect bladder anteriorly; enter anterior peritoneum
4. Serial clamping of cardinal ligaments and uterine vessels
5. Cornual pedicles (round ligament, tube, uteroovarian ligament) last
6. Close colpotomy incorporating uterosacral ligaments (McCall culdoplasty if prolapse present)

Supracervical Hysterectomy

• Same as TAH until uterine artery ligation at the level of the internal cervical os
• Uterine corpus is amputated from the cervix
• Endocervix is cauterized; stump closed with figure-of-eight sutures
• Cervical cancer screening must continue per guidelines
• Contraindicated with malignant/premalignant uterine or cervical disease

Preoperative Considerations

Hysterectomy vs. Supracervical Hysterectomy

• Sexual function
• Urinary incontinence rates
• Constipation

• 5-20% risk of ongoing cyclic cervical bleeding
• 1-2% risk of reoperation (trachelectomy)
• Patients with endometrial hyperplasia, cervical dysplasia, or suspected malignancy are not candidates

Prophylactic Salpingo-Oophorectomy

• Premenopausal women at average ovarian cancer risk (~1.4% lifetime): ovarian conservation is strongly recommended - BSO before age 50 confers an 8.58% excess mortality by age 80 from cardiovascular disease
• Routine opportunistic salpingectomy (tubes only) is now recommended at hysterectomy as it may reduce ovarian cancer risk
• BSO is appropriate for BRCA1/BRCA2 carriers (44% and 17% lifetime risk of ovarian cancer, respectively)

VTE Prophylaxis

• Mechanoprophylaxis (intermittent pneumatic compression)
• Chemoprophylaxis (unfractionated or low-molecular-weight heparin)
• Combination, depending on individual risk level

Postoperative Cystoscopy

Postoperative Complications

Radical Hysterectomy

• Uterus + cervix
• Parametria (cardinal and uterosacral ligaments)
• Upper 1-2 cm of vaginal cuff
• Pelvic lymph node dissection

Special Considerations

GnRH Agonist Pretreatment

• Reduces uterine size
• Allows conversion from abdominal to vaginal approach
• Associated with preoperative rise in hematocrit and shorter hospital stay

Hysterectomy for Pelvic Pain

• ACOG criteria: at least 6 months of pelvic pain without otherwise correctable pathology
• 74-77% of women report relief at 1 year
• ~25% have persistent or worsened pain (associated with multiparity, prior PID, absence of pathology)
• Hysterectomy is generally not indicated for CPP without identifiable uterine pathology

• Berek & Novak's Gynecology, Chapter 27 (Hysterectomy), pp. 1408-1420
• Sabiston Textbook of Surgery, Chapter 120, pp. 2799-2802
• Aarts JWM et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015;(8):CD003677

Note on terminology: "Cornus cancer syndrome" is a phonetic spelling of Cowden (cancer) syndrome - also called Cowden disease or, more broadly, PTEN Hamartoma Tumor Syndrome (PHTS). This is the condition covered below.

Cowden Syndrome (Cowden Cancer Syndrome / PTEN Hamartoma Tumor Syndrome)

Definition

• Prevalence: ~1 in 200,000-250,000
• Penetrance: Nearly complete; 90% of affected individuals show stigmata by age 20

Genetics and Molecular Biology

PHTS Spectrum

• Bannayan-Riley-Ruvalcaba syndrome (BRRS) - earlier-onset variant; macrocephaly, penile lentigines, motor and speech delay, hamartomatous polyps, myopathies, lipomas, hemangiomas; >65% have PTEN mutations; now considered a PHTS variant
• PTEN-related Proteus syndrome
• PTEN-related Proteus-like syndrome
• Adult Lhermitte-Duclos disease (LDD)
• Autism spectrum disorder with macrocephaly

Clinical Features

Pathognomonic Mucocutaneous Findings

1. Multiple trichilemmomas (benign neoplasms differentiating toward outer root sheath) - present in 86% of CS patients; appear on average at age 22; located on central face (around nose, cheeks, orifices, ears)
2. Acral keratoses - verrucous hyperkeratosis on extensor extremities (28%) and palmoplantar translucent keratoses (20%); acral neuromatosis may appear as translucent papules on fingers
3. Papillomatous papules - multiple oral/mucosal papillomas

1. Mucosal lesions - present in >80% of patients; buccal and gingival mucosa most commonly involved; can coalesce into the characteristic cobblestone pattern (seen in 40% of patients)
2. Macrocephaly (head circumference >97th percentile: ≥58 cm in females, ≥60 cm in males)

Systemic Features

Cancer Risks

Diagnostic Criteria (PTEN Hamartoma Tumor Syndrome / Cowden Syndrome)

Major Criteria

• Breast cancer
• Endometrial cancer (epithelial)
• Follicular thyroid cancer
• Multiple GI hamartomas or ganglioneuromas (≥3, excluding hyperplastic polyps)
• Lhermitte-Duclos disease (adult onset)
• Macrocephaly (≥97th percentile)
• Macular pigmentation of the glans penis
• Multiple mucocutaneous lesions (any of the following):
  • Multiple trichilemmomas (≥3, at least one biopsy-proven)
  • Acral keratoses (≥3 palmoplantar keratotic pits and/or acral hyperkeratotic papules)
  • Mucocutaneous neuromas (≥3)
  • Oral papillomas (multiple, ≥3; or biopsy-proven; or dermatologist-diagnosed)

Minor Criteria

• Autism spectrum disorder
• Colorectal cancer
• Esophageal glycogenic acanthosis (≥3)
• Lipomas (≥3)
• Intellectual disability (IQ ≤75)
• Renal cell carcinoma
• Testicular lipomatosis
• Papillary thyroid cancer or follicular variant of papillary thyroid cancer
• Thyroid structural lesions (adenoma, multinodular goiter)
• Vascular anomalies (including multiple intracranial developmental venous anomalies)
• Single GI hamartoma or ganglioneuroma

1. Meeting certain major criterion combinations
2. Three major criteria (one of which must be macrocephaly, LDD, or GI hamartomas)
3. Two major and three minor criteria

Diagnosis

• Definitive: Identification of a heterozygous germline pathogenic variant in PTEN on molecular genetic testing
• Genetic counseling recommended for all patients and at-risk family members
• Prenatal testing possible once a family-specific pathogenic variant is identified
• Thyroid screening: neck ultrasonography + fine-needle aspiration with cytologic analysis

Histopathology of Trichilemmomas

• Variable hyperkeratosis and parakeratosis
• Tumor lobules extend downward from the epidermis
• Glycogen-rich clear cells, peripheral palisading
• Thick, hyalinized basement membrane (distinctive feature)

Management and Surveillance

Cancer Surveillance Recommendations

Skin Lesion Treatment

• Facial papillomas: surgical removal, dermabrasion, CO2 laser - but new lesions continue appearing throughout life
• Rapamycin (mTOR inhibitor) prevents development of mucocutaneous lesions and premature death in animal models, implicating the mTOR pathway in the cutaneous manifestations

Related Syndrome: Bannayan-Riley-Ruvalcaba Syndrome (BRRS)

• Macrocephaly + hypotonia
• Genital lentigines (pigmented speckling of the penis)
• Motor and speech delay, intellectual disability (in ~50%)
• Hypermobile joints
• Lipomas, hemangiomas
• Hamartomatous intestinal polyps (45% incidence)

• Andrews' Diseases of the Skin, pp. 774-775 (Trichilemmoma and Cowden Syndrome)
• Harrison's Principles of Internal Medicine, 22E (2025), p. 2007 (Cowden's syndrome genetics and screening)
• Mulholland & Greenfield's Surgery, p. 3349 (Cowden Syndrome/PHTS)
• Thompson & Thompson Genetics and Genomics in Medicine, 9th ed., p. 3522 (Clinical features)
• Pilarski R et al. Cowden Syndrome and the PTEN Hamartoma Tumor Syndrome. J Natl Cancer Inst 2013;105:1607-1616 (Revised diagnostic criteria)