This decreased surgical time may be more significant for laparoscopic cases, as the most difficult part of the surgery is the detachment of the cervix from the lateral ligaments and from the vagina. This is where most ureteral injuries occur during laparoscopic hysterectomy. This advantage should be balanced with the potential risk of ongoing cyclic bleeding from the cervix that is reportedly between 5% to 20% from the randomized clinical trials and 19% from a prospective observational laparoscopic trial (20). With conservation of the cervix, the patient should be told there is a potential 1% to 2% risk for reoperation to remove the cervix and that trachelectomy is associated with a risk of intraoperative complications. Patients with suspected gynecologic cancers or cervical dysplasia are not candidates for supracervical hysterectomy.
The decision to remove the ovaries and tubes should be based on assessment of risk and not the route of hysterectomy (21). Premenopausal women who are at average risk of ovarian cancer (approximate lifetime risk of 1.4%) should be considered for ovarian preservation when they are undergoing hysterectomy for benign conditions where the ovaries and fallopian tubes are healthy (22). Parous women who have used oral contraceptives may have a substantially lower risk (22). Elective removal of the ovaries and fallopian tubes has declined since 2002 (23).
Salpingo-oophorectomy is performed prophylactically to prevent ovarian cancer and to eliminate the potential for further surgery for either benign or malignant disease. Arguments against prophylactic salpingo-oophorectomy center on the need for earlier and more prolonged hormone therapy and the potential increase risk of cardiovascular disease and bone loss (24,25). There is no overall survival benefit of prophylactic salpingo-oophorectomy in women at average risk for ovarian cancer. In premenopausal women before age 50 years at average risk for ovarian cancer who underwent bilateral salpingo-oophorectomy, there was a significant increase in mortality from cardiovascular disease compared to women who had ovarian preservation (25). A Markov decision analysis model was used to estimate the best strategy for maximizing a woman’s survival when salpingo-oophorectomy is considered in women at average risk for ovarian cancer who are undergoing hysterectomy for benign disease, and in the women who had salpingo-oophorectomy before age 55 years, there was an 8.58% excess mortality by age 80 (26). Both the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists recommend carefully assessing risk, and consideration should be given to conservation of the ovaries in premenopausal women who are at average risk of ovarian cancer (21,22).
Although estrogen therapy is well tolerated and provides good short-term symptomatic relief, recent publications demonstrate that the increased risk of breast cancer in women taking estrogen after hysterectomy makes women reluctant to use it, and long-term compliance with posthysterectomy estrogen therapy is low (27).
In women at risk for ovarian or breast cancer, a formal evaluation with genetic counseling should be offered (see Chapter 37). Salpingo-oophorectomy is associated with a reduced risk of ovarian and breast cancer. Women with a strong family history of ovarian and breast cancer and those who carry germline mutations, BRCA1 or BRCA2 should undergo risk-reducing salpingo-oophorectomy as their lifetime risk is between 10% and 50% (21,22,28,29).