Benefits, Harms, and Costs
- 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).
- 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 <120 g/L) is indicated to reduce morbidity and mortality in the perioperative period when elective surgery is planned (Strong, High).
- 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).
ABBREVIATIONS: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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This document reflects clinical and scientific consensus on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate, and tailored to their needs.
This guideline was written using language that places women at the centre of care. The SOGC is committed to respecting the rights of all people – including transgender, gender non-binary, and intersex people – for whom the guideline may apply. We encourage health care providers to engage in respectful conversation with patients regarding their gender identity and their preferred gender pronouns to be used as a critical part of providing safe and appropriate care. The values, beliefs, and individual needs of each patient and their family should be sought, and the final decision about the care and treatment options chosen by the patient should be respected.