Endometriosis Medical and conservative surgical procedures are successful for treatment of endometriosis (15). Bilateral salpingo-oophorectomy, with or without hysterectomy, should be performed only in patients who do not respond to conservative surgical (resection or ablation of endometriotic implants) or medical therapy (see Chapter 17). Most patients with endometriosis who require hysterectomy have unrelenting pelvic pain or dysmenorrhea. Other less common situations include patients who do not desire future fertility and who have endometriosis involving other pelvic organs, such as the ureter or colon. Hysterectomy with or without salpingooophorectomy provides significant pain relief to the majority of patients. At the time of hysterectomy for endometriosis, consideration should be given to conserving normal ovaries (16).
If a pelvic mass is palpated on pelvic examination, a transvaginal ultrasound should be performed (see Chapter 14). If the mass is suspicious, appropriate consultation with a gynecologic oncologist is recommended. Benign ovarian tumors that are persistent or symptomatic require surgical treatment. If the patient desires fertility, the uterus should be conserved. If fertility is not an issue or if the patient is perimenopausal or postmenopausal, a decision must be made regarding whether the uterus should be removed. In one study, 100 patients who underwent bilateral salpingooophorectomy plus hysterectomy for benign adnexal disease were compared with a group of risk-matched women who underwent bilateral salpingo-oophorectomy without hysterectomy for the same indication (17). There was a significant increase in operative morbidity, estimated blood loss, and the length of hospital stay for patients in whom hysterectomy was performed.
The preoperative discussion should include an informed consent that documents the options, risks, benefits, outcome, and personnel involved with the procedure. The medical record should reﬂect the completion of childbearing and that adequate trial of medical or nonsurgical management was offered, attempted, or refused.
Health Assessment An assessment of a patient’s health status is important in order to obtain an optimal outcome after hysterectomy for benign disease. There are no routinely recommended tests, although individual hospitals may have their own requirements. The patient should be evaluated for risk factors associated with venous thromboembolic events (18). Age, medical history, such as inherited or acquired thrombophilias, obesity, smoking, and hormonal medication, including contraceptives or hormone therapy, may increase the risk.
It is important to assess and correct underlying anemias before surgery. Blood product use can be minimized with preoperative iron supplementation or use of GnRH agonists.
There is a trend toward retention of the cervix at hysterectomy because of the perception that several outcome parameters, including sexual function and pelvic support, are better after a supracervical hysterectomy. Three prospective randomized clinical trials as summarized in a Cochrane review challenge this perception (19). There was no evidence to support the concept that leaving the cervix improves sexual function or lower rates of incontinence or constipation. All of these studies included hysterectomies that were performed by laparotomy. Surgical time was decreased by approximately 11 minutes.