ACOG Committee Opinion
Number 388, November 2007
(Reaffirmed 2013)


Committee on Gynecologic Practice

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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Supracervical Hysterectomy

ABSTRACT: Women with known or suspected gynecologic cancer, current or recent cervical dysplasia, or endometrial hyperplasia are not candidates for a supracervical procedure. Patients electing supracervical hysterectomy should be carefully screened preoperatively to exclude cervical or uterine neoplasm and should be counseled about the need for long-term follow-up, the possibility of future trachelectomy, and the lack of data demonstrating clear benefits over total hysterectomy. The supracervical approach should not be recommended by the surgeon as a superior technique for hysterectomy for benign disease.


Hysterectomy remains one of the most commonly performed surgical procedures in the United States, with the most frequent indications being abnormal uterine bleeding and symptomatic uterine leiomyomata. Variations in surgical technique have been described in an attempt to reduce operative morbidity and reduce the effects of hysterectomy on urinary and sexual function. Supracervical hysterectomy is one such technique in which there has been renewed interest among patients and some gynecologic surgeons. Historically, the supracervical hysterectomy was abandoned in favor of total hysterectomy because of problems related to the retained cervix. The purpose of this document is to review the scientific data for elective supra-cervical hysterectomy in which it is the preference of the patient or physician to preserve the cervix at the time of hysterectomy unrelated to the indications for surgery.

Techniques for supracervical hysterectomy, defined as removal of the uterine corpus with preservation of the cervix, are well described for both the abdominal and laparoscopic approaches (1, 2). Features common to both the laparoscopic and open techniques of supracervical hysterectomy are removal of the corpus at or below the level of the internal os and attempted ablation of the endocervical canal after removal of the corpus (1). In laparoscopic supracervical hysterectomy, morcellation of the uterine fundus is performed to facilitate its removal through the port site incisions (1).

Women with known or suspected gynecologic cancer, current or recent cervical dysplasia, or endometrial hyperplasia are not candidates for a supracervical procedure (3–5). Candidates for elective supracervical hysterectomy must have normal results from a recent cytologic cervical examination and normal gross appearance of the cervix documented before surgery (3–5). Clinicians also should consider testing for high-risk human papillomavirus to identify patients who could be at risk for future cervical neoplasia. Amputation of the uterine corpus in the abdominal approach and morcellation of the corpus in the laparoscopic approach require adequate preoperative assessment of the endometrial cavity to exclude neoplasm (3–5).

Possible benefits of supracervical hysterectomy with regard to perioperative morbidity are not supported by recent evidence. In three prospective randomized controlled trials that did not include laparoscopic procedures, no difference in complications, including infection; blood loss requiring transfusion; or urinary tract, bowel, or vascular injury, was seen between women randomized to total abdominal hysterectomy (TAH) and supracervical abdominal hysterectomy (3–5). Length of hospital stay (5.2 versus 6 days, P = .04) and duration of surgical procedure (59.5 versus 71.1 minutes P <.001) were significantly shorter for women randomized to supracervical hysterectomy in European studies, but no significant difference was seen in any outcome measured in the only prospective randomized trial of TAH versus supracervical hysterectomy conducted in the United States (3–5). Reported rates of postoperative cyclical vaginal bleeding in women randomized to supracervical hysterectomy were 5–20% in these three prospective trials. Of the two trials that reported reoperation rates, 1.5% of the participants had a second operation to remove the cervix less than 3 months from the time of hysterectomy.

Choosing to preserve the cervix to reduce adverse effects of hysterectomy on sexual and urinary function also is not supported by data from prospective randomized trials. Differences in preoperative and postoperative stress or urge incontinence, urinary frequency, and incomplete bladder emptying were not statistically significant between women randomized to supracervical hysterectomy or TAH in either the U.S. or British trials (3, 4). The Danish Hysterectomy Group found a higher incidence of urinary incontinence in women randomized to supracervical hysterectomy (P = .043) (5). Sexual satisfaction was reported with similar frequency preoperatively and 1 year postoperatively by women in the Danish study, irrespective of type of hysterectomy performed (5). Frequency of intercourse, frequency of orgasm, and rating of sexual relationship with a partner measured preoperatively and postoperatively were similar for the supracervical hysterectomy and TAH groups in the British study (4). In the U.S. study, there were no differences between the supracervical hysterectomy and the TAH groups in sexual functioning and measure of health-related quality of life, including sexual desire, orgasm frequency and quality, and body image, measured 2 years after surgery (6).

Because there have been no randomized, controlled trials of laparoscopic supracervical hysterectomy compared with either TAH or laparoscopically assisted vaginal hysterectomy (LAVH), evidence regarding the potential benefits of this technique is limited to retrospective series. In a retrospective comparison of laparoscopic supracervical hysterectomy with LAVH, less blood loss, shorter operating time, and fewer complications were found in the patients who had supracervical hysterectomy (7). In contrast, the recent experience of a large managed care organization was documented, indicating longer operating time for laparoscopic supracervical hysterectomy compared with TAH but less blood loss, shorter hospital stay, and fewer major complications for laparoscopic supracervical hysterectomy compared with TAH (8). Although only reported in series with small numbers of patients, the long-term complications of laparoscopic supracervical hysterectomy include cyclical vaginal bleeding in 11–17% of cases and the need for trachelectomy because of symptoms in 23% of cases at a mean of 14 months from the time of hysterectomy (9, 10). The potential risks as well as benefits of laparoscopic supra-cervical hysterectomy should be carefully considered by the individual surgeon and patient until data from prospective randomized controlled trials comparing this technique with LAVH or TAH are available.

An additional risk of supracervical hysterectomy relates to the development of benign or neoplastic conditions that require future removal of the cervical stump. Complications of trachelectomy reported in the largest published series (310 cases) include a 9% incidence of infection and perioperative bleeding and a 2% incidence of intraoperative bowel injury. Fewer complications were seen with vaginal trachelectomy than with abdominal trachelectomy (11).

Although data from uncontrolled series may suggest a benefit from preserving the cervix, review of recently published Level I evidence reveals no advantage to the supracervical abdominal technique with regard to surgical complications, urinary symptoms, or sexual function in women undergoing hysterectomy for symptomatic uterine leiomyomata or abnormal uterine bleeding (3–5). Despite the potential advantages of shorter hospital stay and less blood loss afforded by the laparoscopic supracervical approach, there are no prospective data comparing laparoscopic supracervical hysterectomy with either LAVH or TAH.

Patients electing supracervical hysterectomy should be carefully screened preoperatively to exclude cervical or uterine neoplasm and should be counseled about the need for long-term follow-up, the possibility of future trachelectomy, and the lack of data demonstrating clear benefits over total hysterectomy. The supracervical approach should not be recommended by the surgeon as a superior technique for hysterectomy for benign disease.

References

  1. Jenkins TR. Laparoscopic supracervical hysterectomy. Am J Obstet Gynecol 2004;191:1875–84.
  2. Parker WH. Total laparoscopic hysterectomy and laparoscopic supracervical hysterectomy. Obstet Gynecol Clin North Am 2004;31:523–37, viii.
  3. Learman LA, Summitt RL Jr, Varner RE, McNeeley SG, Goodman-Gruen D, Richter HE, et al. A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Total or Supracervical Hysterectomy (TOSH) Research Group. Obstet Gynecol 2003;102:453–62.
  4. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med 2002;347:1318–25.
  5. Gimbel H, Zobbe V, Andersen BM, Filtenborg T, Gluud C, Tabor A. Randomised controlled trial of total compared with subtotal hysterectomy with one-year follow up results. BJOG 2003;110:1088–98.
  6. Kuppermann M, Summitt RL Jr, Varner RE, McNeeley SG, Goodman-Gruen D, Learman LA, et al. Sexual functioning after total compared with supracervical hysterectomy: a randomized trial. Total or Supracervical Hysterectomy Research Group. Obstet Gynecol 2005;105:1309–18.
  7. El-Mowafi D, Madkour W, Lall C, Wenger JM. Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 2004; 11:175–80.
  8. Hoffman CP, Kennedy J, Borschel L, Burchette R, Kidd A. Laparoscopic hysterectomy: the Kaiser Permanente San Diego experience. J Minim Invasive Gynecol 2005;12:16–24.
  9. Okaro EO, Jones KD, Sutton C. Long term outcome following laparoscopic supracervical hysterectomy. BJOG 2001; 108:1017–20.
  10. Ghomi A, Hantes J, Lotze EC. Incidence of cyclical bleeding after laparoscopic supracervical hysterectomy. J Minim Invasive Gynecol 2005;12:201–5.
  11. Hilger WS, Pizarro AR, Magrina JF. Removal of the retained cervical stump. Am J Obstet Gynecol 2005;193:2117–21.

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Supracervical Hysterectomy.

ACOG Committee Opinion no. 388.

American College of Obstetricians and Gynecologists.

Obstet Gynecol 2007;110:1215-7.