Introduction

Key Clinical Decision: Determining the Route and Method of Hysterectomy has been developed to provide information that physicians can use when choosing between abdominal and vaginal hysterectomy with or without laparoscopic assistance. This document is a compilation of some of the evidence regarding the selection of the route and method of hysterectomy for patients with benign disease and includes criteria physicians can apply to individual patients who need hysterectomies. By incorporating the evidence into their clinical decision making, practitioners can develop personal or organizational guidelines that will assist in choosing the route of hysterectomy that is best for each patient. Throughout this document, vignettes illustrate key points in the decision process.

Background

Every year more than 590,000 American women undergo hysterectomies, making the procedure the second most common surgery among reproductive-aged women in the United States, resulting in an estimated annual cost exceeding $5 billion. The vast majority of these surgeries are performed for benign conditions. Studies of hysterectomy practice show that in the past, surgeons performed approximately 75% of these procedures abdominally despite well-documented evidence that, when compared with unassisted vaginal hysterectomy, abdominal hysterectomy was reported to have a higher incidence of complications, a longer length of hospital stay and convalescence, and greater hospital charges. The advantages of vaginal hysterectomy over abdominal hysterectomy have prompted numerous investigators to recommend vaginal hysterectomy for women whose conditions permit the approach. Data obtained from hysterectomy surveillance studies show that during the early 1990s, there was a 10% to 15% decline in the percentage of abdominal hysterectomies performed.

Until recently, most physicians limited the use of vaginal hysterectomy for benign conditions confined to the uterus to the following indications:

•	Uterine prolapse

•	Small symptomatic leiomyomata

•	Recurrent or severe dysfunctional uterine bleeding

•	Carcinoma in situ of the cervix uterine bleeding

Traditionally, vaginal hysterectomy was contraindicated when the vaginal route was presumed inaccessible or when more serious pathologic conditions were thought to exist, such as:

•	Endometriosis

•	Pelvic adhesive disease

•	Adnexal pathology

•	Chronic pelvic pain

•	Chronic pelvic inflammatory disease

In addition, many physicians hesitated to perform vaginal hysterectomy in cases of nulliparity, previous pelvic surgery (including one or more cesarean sections), a moderately enlarged uterus, or when an oophorectomy was necessary.