Choices in Hysterectomy

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Dr. Hugo Verhoeven: "Good morning, my name is Hugo Verhoeven. I'm from Dusseldorf in Germany, and I'm a member of the Editorial Advisory Board of OBGYN.net Infertility. It is a great pleasure for me to have the chance to talk this morning with Professor Liselotte Mettler of the Kiel University in Germany. She is well-known for her work in the field of endoscopic surgery."

Professor Liselotte Mettler: "Good morning."

Dr. Hugo Verhoeven: "One of the interesting topics at this meeting in Las Vegas was state of the art hysterectomy. I would like you to give an overview on how we can perform hysterectomies today."

Professor Liselotte Mettler: "Yesterday, we had an interesting post-graduate course on the topic of hysterectomies. So it seems that now with the new concepts of laparoscopy, we can offer our patients six kinds of hysterectomies. There is the normal abdominal hysterectomy, the normal vaginal hysterectomy, and we have the laparoscopic-assisted vaginal hysterectomy in different steps where we can take a larger part by laparoscopy and then a minor part by vaginal approach. But we can also do the whole preparation laparoscopically in cancer cases, all the way down to the cervix, and just pull out the uterus through the vagina. Then we have three kinds of hysterectomies where we apply the supracervical aspect - that means we leave the cervix in. We can do this with a so-called supracervical hysterectomy by laparoscopy, which is done by many colleagues in the United States. We in Kiel do the classic intrafascial supracervical hysterectomy where we take the uterus supracervically, but core out in addition the endocervical zone, which takes out the whole transformation zone so cancer development is stopped and is, thus, very uncommon."

Dr. Hugo Verhoeven: "I think that is very important for our listeners - if you leave in the lower part of the uterus, the cervix, that's the place where cervical cancer will exist. What you are doing, to prevent that patient from having cancer of the cervix later on, is taking out the dangerous part of the cervix where the cancer will appear, and in addition you take out the endocervical zone - is that correct?"

Professor Liselotte Mettler: "Correct, and from the six kinds of hysterectomy that are offered now, I would just do the supracervical hysterectomy - leaving the cervix and coring out the cervix. So the danger has gone down tremendously by detection of premalignant lesions of the cervix by the pap smear, which is done worldwide. But still, your question is correct because if you leave the cervix in, the patient can still develop cancer. If you have a healthy organ, which is the cervix, and only the uterus has the myoma, then we take only the uterus. If we have malignancies in the uterus, we will take out the whole uterus and use a LAVH. But now we are discussing benign indications and if this cervix is healthy, why should we take it out? It is an organ that is centric in the pelvic floor - there are vessels, there are nerves around it. It has connections to the bladder, to the rectum, and you are destroying all this if you take out the cervix. So our concept is to leave the cervix in, in patients that want it, and emphasize the idea that it's minor surgery - and it is minor surgery, compared to taking the whole uterus out. We leave it in, and we also do careful pap smears as before, but if the patient has the transformation zone out, her risk of severe cancer is minimal because all the squamal cells are taken out and only the cylindrical cells are left in. Only 0.6% of all cervical cancers are developing from cylindrical epithelia."

Dr. Hugo Verhoeven: "Okay. Tell me, what are the indications for those six possibilities? For instance, when would you do a laparotomy, when are you doing laparoscopy, and what technique do you prefer for the different indications?"

Professor Liselotte Mettler: "This is the daily discussion we have with our patients that are admitted, and the one that we always prefer is vaginal surgery. If the uterus is not too big - or if it's mobile - it comes out vaginally. We now follow this choice with a laparoscopic supracervical hysterectomy; it would be the second choice in a not-too-large uterus with myomas. If it is very large, I would go to a laparotomy. If I have to do additional vaginal prolapse - in rather corrective situations - I generally stay with the vaginal approach. So it's relative to every patient's circumstances, I would say, but in all the malignant cases we do a laparotomy combination. Sometimes we elevate, and if there is any history of pathology on the cervix of the patient, I take the cervix out. It is both possible and necessary to use LAVH, because it cannot come out vaginally. If the patient has had previous operations, caesarian sections, some abdominal pain, or if suspicious endometriosis is present, then I would combine and do a laparoscopic-assisted vaginal hysterectomy."

Dr. Hugo Verhoeven: "Let's talk percentages. No malignancy - what is the frequency of laparotomy or vaginally-assisted procedures, compared with the laparoscopically-assisted procedures?"

Professor Liselotte Mettler: "I would say in our unit we do about 70% vaginal, surgical, laparoscopic-assisted procedures, and that leaves another 30% for the laparotomy approach in larger tumors. Of course, that is my view. In this seminar, we also had colleagues like Tom Lyons, who prefers to take out one kilo uteri with a laparoscopic assisted vaginal hysterectomy. I do not totally understand this, because it takes a long time. However they want to put it, with a large uterus, I still say why not do a simple laparotomy and finish the case in a hour?"

Dr. Hugo Verhoeven: "Because that was my question - don't you think that 30% is still a high frequency when we compare that with the international experience?"

Professor Liselotte Mettler: "In international general experience it is not, but in our laparoscopic society where you have more fans of laparoscopic-assisted vaginal approaches, I would say it's a normal number. But if you look internationally, 30% is still very advanced because many are doing nothing of the kind."

Dr. Hugo Verhoeven: "Thank you very much, Professor Mettler, for this interview."

Professor Liselotte Mettler: "Thank you, my pleasure."