No. 377-Hysterectomy for Benign Gynaecologic Indications

ABSTRACT Objective To assist physicians performing gynaecologic surgery in decision making surrounding hysterectomy for benign indications. Intended Users Physicians, including gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers. Target Population Adult women (18 years and older) who will undergo hysterectomy for benign gynaecologic indications. Options The approach to hysterectomy and utility of concurrent surgical procedures are reviewed in this guideline. Evidence For this guideline relevant studies were searched in the PubMed, Medline, and Cochrane Library databases. The following MeSH search terms and their variations for the last 5 years (2012-2017) were used: vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy, and total vaginal hysterectomy. Validation methods The content and recommendations were drafted and agreed upon by the principal authors and members of the Gynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2). The Summary of Findings is available upon request. Benefits, Harms, and Costs Hysterectomy is common, yet surgical practice still varies widely among gynaecologic physicians. This guideline outlines preoperative and perioperative considerations to improve the quality of care for women undergoing benign gynaecologic surgery. Guideline Update This Society of Obstetricians and Gynaecologists of Canada clinical practice guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. Sponsors This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1Technicity is defined as the proportion of hysterectomies performed by a minimally invasive route (laparoscopic, laparoscopic-assisted, and vaginal). Increased technicity index is associated with improved surgical quality and patient care (High). 2Minimally invasive approaches to hysterectomy are associated with fewer perioperative complications compared to laparotomy (High). 3Higher-volume hospitals and surgeons are more likely to have higher technicity and lower complication rates (High). 4Same-day discharge protocols following minimally invasive hysterectomy are cost-effective, do not increase complications or re-admission rates, and are associated with high patient satisfaction (Moderate). 5Urinary tract injuries are comparable among surgical approaches to hysterectomy (Moderate). 6Laparotomy or mini-laparotomy may be appropriate as an alternative approach in specific circumstances depending on patient factors, indication for surgery, and underlying pathology (Moderate). 7The risk of vaginal cuff dehiscence is rare and not related to the choice of suture material or route of closure (Moderate). 8Supracervical hysterectomy has not been shown to preserve sexual function, decrease pelvic organ prolapse, or reduce incidence of urinary tract injuries compared to total hysterectomy (Moderate). 9For women with uterine leiomyomas, preoperative medical treatment with leuprolide acetate or ulipristal acetate can reduce myoma size, decrease bleeding, and correct anemia. Risks and benefits of medical treatment should be discussed preoperatively (High). 10Mechanical bowel preparation is not routinely required prior to gynaecologic surgery for benign disease (High). 11Removal of normal ovaries at the time of hysterectomy decreases the risk of ovarian cancer but may be associated with health ramifications. Bilateral oophorectomy may lead to acute development of menopausal symptoms in premenopausal women and has not been shown to offer a survival benefit in the absence of genetic predisposition to ovarian cancer (High). 12Hysterectomy alone affects ovarian reserve (High). 13Opportunistic salpingectomy at the time of hysterectomy is expected to decrease the incidence of high-grade serous ovarian cancer (Low). 14There is no strong evidence to support routine uterosacral or vaginal vault suspension at the time of hysterectomy in patients without pelvic organ prolapse (Low). Recommendations 1Hysterectomy for benign indications should preferably be approached by either vaginal or laparoscopic routes (Strong, High). 2Vaginal hysterectomy is still considered the preferred route of hysterectomy, but laparoscopic hysterectomy is an appropriate alternative minimally invasive approach (Strong, Moderate). 3Correction of preoperative anemia (hemoglobin 4Preoperative antibiotic prophylaxis and measures to decrease risk of venous thromboembolism are recommended for all patients undergoing hysterectomy (Strong, High). 5Women should be counselled about the benefits and risks of removing the ovaries at the time of the hysterectomy. This should include discussion about the risk of ovarian cancer as well as the long-term health implications of earlier menopause linked to bilateral oophorectomy (Strong, Moderate). 6Opportunistic salpingectomy can be considered at the time of hysterectomy but the planned surgical approach should not be changed for this sole purpose (Strong, Low). 7Urinary tract injury is a known complication of hysterectomy, and clinicians should have a low threshold for further investigation in cases where injury is suspected. Surgeons performing hysterectomy should have access to diagnostic cystoscopy, individually or though consultation, to evaluate for bladder and ureteric integrity (Strong, Moderate). 8If patients with endometriosis are planning to undergo hysterectomy, full excision of local endometriosis should be performed concurrently (Strong, Moderate).