No. 377-Hysterectomy for Benign Gynaecologic Indications



      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.


      The approach to hysterectomy and utility of concurrent surgical procedures are reviewed in this guideline.


      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.


      This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada.

      Summary Statements

      • 1
        Technicity 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).
      • 2
        Minimally invasive approaches to hysterectomy are associated with fewer perioperative complications compared to laparotomy (High).
      • 3
        Higher-volume hospitals and surgeons are more likely to have higher technicity and lower complication rates (High).
      • 4
        Same-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).
      • 5
        Urinary tract injuries are comparable among surgical approaches to hysterectomy (Moderate).
      • 6
        Laparotomy or mini-laparotomy may be appropriate as an alternative approach in specific circumstances depending on patient factors, indication for surgery, and underlying pathology (Moderate).
      • 7
        The risk of vaginal cuff dehiscence is rare and not related to the choice of suture material or route of closure (Moderate).
      • 8
        Supracervical 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).
      • 9
        For 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).
      • 10
        Mechanical bowel preparation is not routinely required prior to gynaecologic surgery for benign disease (High).
      • 11
        Removal 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).
      • 12
        Hysterectomy alone affects ovarian reserve (High).
      • 13
        Opportunistic salpingectomy at the time of hysterectomy is expected to decrease the incidence of high-grade serous ovarian cancer (Low).
      • 14
        There is no strong evidence to support routine uterosacral or vaginal vault suspension at the time of hysterectomy in patients without pelvic organ prolapse (Low).


      • 1
        Hysterectomy for benign indications should preferably be approached by either vaginal or laparoscopic routes (Strong, High).
      • 2
        Vaginal hysterectomy is still considered the preferred route of hysterectomy, but laparoscopic hysterectomy is an appropriate alternative minimally invasive approach (Strong, Moderate).
      • 3
        Correction of preoperative anemia (hemoglobin <120 g/L) is indicated to reduce morbidity and mortality in the perioperative period when elective surgery is planned (Strong, High).
      • 4
        Preoperative antibiotic prophylaxis and measures to decrease risk of venous thromboembolism are recommended for all patients undergoing hysterectomy (Strong, High).
      • 5
        Women 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).
      • 6
        Opportunistic salpingectomy can be considered at the time of hysterectomy but the planned surgical approach should not be changed for this sole purpose (Strong, Low).
      • 7
        Urinary 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).
      • 8
        If patients with endometriosis are planning to undergo hysterectomy, full excision of local endometriosis should be performed concurrently (Strong, Moderate).

      Key Words


      AH (abdominal hysterectomy), BSO (bilateral salpingo-oophorectomy), CI (confidence interval), GnRHa (gonadotropin-releasing hormone agonist), HR (hazard ratio), LAVH (laparoscopic assisted vaginal hysterectomy), LH (laparoscopic hysterectomy), POP (pelvic organ prolapse), RH (robotic assisted hysterectomy), SBO (small bowel obstruction), SOGC (Society of Obstetricians and Gynaecologists of Canada), TH (total hysterectomy), TI (technicity index), TLH (total laparoscopic hysterectomy), USLS (uterosacral ligament suspension), VH (vaginal hysterectomy)
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