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Obstetrics & Gynecology 2003;102:301-305
© 2003 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Total Versus Subtotal Hysterectomy: A Survey of Gynecologists

Nadine Zekam, MD, Yinka Oyelese, MD, Katie Goodwin, Caroline Colin, Irit Sinai, PhD and John T. Queenan, MD

From the Department of Obstetrics & Gynecology, Georgetown University Medical Center, Washington, DC.


   ABSTRACT
TOP
ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: To estimate the attitudes and practice of gynecologists in the Washington, DC, Maryland, and Virginia area regarding total versus subtotal abdominal hysterectomy.

METHODS: A questionnaire with 18 questions on physicians’ attitudes and practice regarding total versus subtotal hysterectomy was mailed to 1647 gynecologists in Washington, Maryland, and Virginia.

RESULTS: The corrected response rate was 51.2%. Forty-five percent of respondents stated that they always removed the cervix. The most common reason cited was to eliminate the risk of cervical cancer. The most common reason for subtotal hysterectomy was surgical difficulty leading to an intraoperative change of procedure. Only 17.8% of respondents always counseled women regarding the advantages and disadvantages of both total and subtotal hysterectomy; 63% rarely or never did. Nineteen percent always offered women a choice between the procedures; 61% rarely or never did. Eighty-eight percent of respondents felt that the risk of cancer in the cervical stump was small or negligible. Gender of the physicians or year of completion of residency made no significant impact on patients being counseled about both procedures or being offered a choice between the two.

CONCLUSION: Most gynecologists surveyed favor total abdominal hysterectomy over subtotal hysterectomy. Few counsel women regarding the options of total and subtotal hysterectomy or offer a choice between the procedures. Given that there are no convincing data proving the superiority of either procedure over the other, it may be reasonable to discuss the potential advantages and disadvantages of both procedures with women undergoing hysterectomy for benign disease and to offer them a choice.

Approximately 600,000 hysterectomies are performed each year in the United States, making the procedure second only to cesarean delivery as the most frequently performed major abdominal operation.1,2 National figures show that 98% of hysterectomies involve removal of the cervix.2,3 In recent years, the debate regarding whether or not the cervix should be removed at the time of hysterectomy has received considerable attention, both in the medical literature and in the lay media.4–11

Advocates for removal maintain that it eliminates the risk of cancer of the cervix and prevents complications related to retention of the cervical stump such as intermittent bleeding and pelvic pain. They argue that it has never been demonstrated that the cervix has a role in urinary, bowel, or sexual function. Proponents of subtotal hysterectomy argue that preserving the cervix has a potential beneficial effect on urinary, bowel, and sexual function and reduces the incidence of postoperative prolapse because the supports of the uterus are not divided. Furthermore, they contend that not removing the cervix results in shorter operating time, less difficult surgery with the benefits of reduced patient morbidity, a reduction in hospitalization time, and fewer surgical complications. Finally, they argue that it does not make sense to remove an organ that is not diseased.

There are those who believe that subtotal hysterectomy is a procedure for the inexperienced surgeon. In fact, the 1974 edition of Bonney’s Gynaecological Surgery12 only included a description of the technique of subtotal hysterectomy "with apologies, recognizing that every surgeon must go through a period of inexperience that may provide an excusable occasion for the adoption of this incomplete operation."

In 1997, before data were available from any adequately controlled trials comparing outcomes from subtotal and total abdominal hysterectomy, Scott et al presented a decision analysis weighing the advantages and disadvantages of each procedure.8 These authors concluded that, based on available data at the time, the recently proposed benefits from subtotal hysterectomy were not well proven and total abdominal hysterectomy remained the procedure of choice for most women. They noted that the risks for development of cervicovaginal cancer and long-term adverse effects on sexual or urinary function were low in both groups. However, it was not until recently that a published randomized, double-blinded trial compared outcomes of supracervical versus total abdominal hysterectomy.11

We sought to study the views and practices of gynecologists in the city of Washington and the states of Maryland and Virginia regarding subtotal versus total abdominal hysterectomy for benign disease.


   MATERIALS AND METHODS
TOP
ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
We constructed a questionnaire of 18 questions modeled after a similar survey from the United Kingdom.5 This was mailed out to gynecologists practicing in the city of Washington and the states of Maryland and Virginia. A stamped, self-addressed envelope and an explanatory letter from the authors were included with each questionnaire, which was designed so that physician responses were anonymous. There was no attempt to follow-up nonrespondents, nor did we obtain their demographic data or other characteristics. Questions were about physician demographics, the number of total and subtotal hysterectomies performed within the last 12 months, and reasons that the physicians had chosen a total or subtotal hysterectomy. We assumed that these procedures were performed by laparotomy; we did not inquire about laparoscopic procedures. We also asked the physicians whether they perceived the incidence of cervical cancer after subtotal hysterectomy to be high, low, or negligible. Respondents were asked whether their patients were counseled about the potential advantages and disadvantages of both total and subtotal hysterectomy and if they were offered a choice between the two procedures. We asked which procedure the respondents would prefer if they or their partner were to have a hysterectomy for benign disease. We also inquired if the physicians felt either procedure had advantages over the other in relation to bowel, urinary, or sexual function or prolapse, and if they were aware of any studies proving such a benefit. Finally, we asked if the respondents would consider performing a subtotal hysterectomy on a woman with previous abnormal Papanicolaou smears who had been adequately treated.

Descriptive statistical analyses were conducted for all data using SPSS 10 for Windows (SPSS Inc., Chicago, IL) and StatXact-5 for Windows (Cytel Software Corp., Cambridge, MA). Planned comparisons included an evaluation of attitude toward subtotal abdominal hysterectomy by sex and year of training of the respondent. The proportions of male and female practitioners who always or frequently counseled women about both procedures and who always or frequently offered a choice between the two were compared with proportions of those who rarely or never did, using the {chi}2 or Fisher exact test as appropriate. Similar comparisons were made by year of training, with completion of training in 1995 and before compared with completion of training in 1996 or later. The selection of 1995 and 1996 was arbitrary. P values of .05 or less were accepted as statistically significant. Odds ratios and 95% confidence intervals were also calculated.


   RESULTS
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Of the 1647 questionnaires that were mailed out, 143 were disqualified because of retirement, death, or moving out of the area or because the questionnaire was returned as undeliverable. Seven hundred seventy questionnaires were returned, for a corrected response rate of 51.2%. Respondent characteristics are shown in Table 1Go.


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  		Table 1. Respondent Characteristics
 
The median number of total abdominal hysterectomies that the respondents claimed to have performed in the past year was 12 (range 0–400). The median number of subtotal hysterectomies was zero (range 0–100). Male respondents performed a median of 12 total abdominal and zero subtotal hysterectomies, respectively, in the past year, compared with 11 total abdominal and zero subtotal hysterectomies, respectively, for females. Three hundred forty-eight respondents (45.2%) stated that they always performed a total hysterectomy. The most common reason given for performing a total abdominal hysterectomy (307 respondents [39.9%]) was to remove the risk of cervical cancer. Other reasons cited included no need for further Papanicolaou smears and a preoperative suspicion of premalignant or malignant disease (Table 2Go). Four hundred thirty-five respondents gave reasons for performing a subtotal hysterectomy. The most common reason was unexpected surgical difficulty, resulting in an intraoperative change of plan (300 respondents [68.9% of those who answered this question]). The next most common reason was patient choice (215 respondents [49.4% of those who answered this question]). A belief that subtotal hysterectomy had some benefits was the reason cited by 158 respondents (36.3% of those who answered this question). Five hundred seventy-one respondents (74.2%) felt that the risk of developing cancer in the cervical stump was small, and 105 (13.6%) felt the risk was negligible. Responses regarding counseling patients and offering a choice between the two procedures are summarized in Tables 3Go and 4Go. The proportions of practitioners who counsel patients regarding the potential advantages and disadvantages of both total and subtotal abdominal hysterectomy by gender and year of training are given in Table 5Go. The proportions of practitioners who offer a choice between the procedures by gender and year of training are given in Table 6Go. There was no statistically significant difference between male and female gynecologists in counseling patients about the potential benefits and disadvantages of both total and subtotal abdominal hysterectomy or offering them a choice between the procedures (Table 5Go). Similarly, there was no statistically significant difference based on year of completion of residency (completion of residency in 1996 or later versus before 1996). Five hundred twenty-five respondents (68.2%) stated that they would not perform a subtotal hysterectomy on a woman who had a history of abnormal Papanicolou smears, which had been adequately treated; 213 respondents (27.7%) would. Six hundred fourteen (79.7%) said the choice would depend on the patient’s history.


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  		Table 2. Reasons for Performing a Total Abdominal Hysterectomy
 

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  		Table 3. Do You Routinely Counsel Women About the Potential Benefits and Disadvantages of Both Subtotal and Total Hysterectomy?
 

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  		Table 4. Do You Offer Women a Choice Between Subtotal and Total Hysterectomy?
 

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  		Table 5. Association of Gender and Year of Training of Physicians With Counseling on Total and Subtotal Hysterectomy
 

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  		Table 6. Association of Gender and Year of Training of Physicians With Offering a Choice of Procedure
 
Six hundred fifteen respondents (79.9%) stated that if they or their partner were to have a hysterectomy for benign disease, they would prefer removal of the cervix; 116 respondents (15.3%) stated that they would opt for conservation of the cervix. Most respondents felt that neither procedure offered any benefit with respect to bowel function (537 [69.7%]), sexual function (399 [51.8%]), or urinary function (463 [60.1%]). However, 271 (35.2%) felt that a subtotal hysterectomy offered some protection against prolapse. The numbers of respondents claiming that they were aware of studies showing that their choice of operation had a beneficial effect on urinary function, bowel function, sexual function, and prolapse were 58, 24, 132, and 124, respectively. Six hundred fifty-nine respondents (85.6%) felt that performing a subtotal hysterectomy did not reflect surgical inexperience; 87 respondents(11.3%) felt it did.


   DISCUSSION
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This, to our knowledge, is the first survey to be carried out in the United States of views of gynecologists regarding removal or conservation of the cervix at hysterectomy for benign disease. The survey demonstrates that subtotal hysterectomy is an unpopular choice among gynecologists in the Washington, DC, Maryland, and Virginia area; 79.9% of respondents would opt for total abdominal hysterectomy were they or their partner to have an abdominal hysterectomy for benign disease. Thakar et al5 carried out a similar survey in the United Kingdom in 1998; they found that 78% of British gynecologists would opt for removal of the cervix. Conversely, a recent survey of Danish gynecologists found that subtotal hysterectomy was the favored procedure in that country.10 In the current survey, 45.2% of surveyed gynecologists said that they routinely remove the cervix at the time of abdominal hysterectomy. The most frequently stated reason (39.9%) is to remove the risk of cervical cancer, even though 88% state that the risk of developing cancer in the cervical stump is low or negligible. In a Scandinavian study of 1104 women who had subtotal hysterectomy for benign disease, two (0.2%) developed cervical cancer over a 10-year period.13 In women who have had a subtotal hysterectomy and develop cervical cancer, the absence of the uterus does not adversely affect survival, but the diagnosis may be made later than in women with an intact uterus.14 However, radiation therapy produces equal survival rates in cervical cancer patients with or without an intact uterus.14,15 Johns has argued6 that the risk of cancer in the cervical stump is lower than that of vaginal cancer, yet no one seriously advocates removal of the vagina at the time of hysterectomy to prevent vaginal cancer. It is important, however, to emphasize to women who do have a subtotal hysterectomy that regular Papanicolaou smear screening for cervical cancer is essential because these women may wrongly assume otherwise.

In our survey there was no significant difference between male and female gynecologists in counseling women regarding the advantages and disadvantages of total and subtotal hysterectomy, nor in offering the women a choice between the procedures. Similarly, there was no statistically significant difference in counseling women or offering them a choice between the two procedures between gynecologists who completed their residencies in 1995 or earlier and those who completed their training in 1996 or later.

It is interesting to note that although most gynecologists had a choice of procedure, the majority were unaware of any scientific data to support this choice. Even though some stated that subtotal hysterectomy may have a beneficial effect on bladder, bowel, and sexual function and may prevent prolapse, this did not translate into these physicians performing a greater number of subtotal hysterectomies. In an era where practicing evidence-based medicine is encouraged, it seems that the choice of surgical procedure is based more on habit and surgical training than on any objective evidence. Only 19.1% of gynecologists routinely offered their patients a choice between removal and conservation of the cervix, and even fewer (17.8%) routinely counseled their patients about the potential benefits and advantages of both procedures. Women are now likely to be better educated about their options because of improved access to information, accurate or inaccurate, through the Internet and media. Therefore, it is important that gynecologists be well informed about different management modalities, present these to the patient, and allow the patient to make an informed choice. Thakar et al recently published the first double-blinded, randomized, controlled trial comparing outcomes of subtotal and total abdominal hysterectomy.11 Apart from a shorter hospital stay, more rapid recovery, fewer short-term complications, and infrequent cyclical bleeding with subtotal hysterectomy, no major differences were found in outcomes between the procedures. In particular, no statistically significant differences were found with respect to urinary, bowel, and sexual function. Also, neither procedure was found to adversely affect urinary, bowel, or sexual function at 12 months’ follow-up, consistent with the conclusions of Scott et al’s prior decision analysis.8 Our survey was carried out before the publication of Thakar et al’s study.

Our survey has limitations inherent to postal surveys. First, the response rate of 51.2% means that the results may not be applicable to all gynecologists in the surveyed area. Furthermore, even with a 100% response, the results obtained from this geographical area cannot be generalized to all gynecologists in the United States.1 Hysterectomy surveillance studies by the Centers for Disease Control and Prevention have indicated that there is tremendous geographical variation in the practice of gynecologists in the United States regarding hysterectomy.1 Also, the assumption is made that the gynecologists reliably reported their actual practices and attitudes. Answers to questions on things such as the number of procedures performed and the reasons they were performed are subject to recall bias. Regardless of these limitations, we believe that our survey yields clinically useful results. First, it is clear that the majority of the surveyed gynecologists do not counsel their patients regarding the potential benefits and disadvantages of subtotal versus total hysterectomy. Furthermore, few gynecologists offer their patients a choice between the procedures. Our study also demonstrates that gynecologists frequently have opinions about whether the cervix should be removed or conserved. However, the majority who had views did admit that they were unaware of any studies to support their opinions.

Given the frequency with which hysterectomy is performed in the United States, further studies examining the benefits or disadvantages of total and subtotal hysterectomy are necessary. Neither procedure has been demonstrated to be superior to the other. It is our opinion, therefore, that it is reasonable that women undergoing hysterectomy for benign conditions be counseled regarding the potential benefits and disadvantages of both procedures and offered a choice between the two.


   Footnotes
 
This study was funded by a grant from the Dougherty Foundation.

The authors thank Michael Cusick for his help in the statistical analysis and Dr. Anthony R. Scialli for advice on study design and statistical methods.

doi:10.1016/S0029-7844(03)00529-5

Received December 16, 2002. Received in revised form March 21, 2003. Accepted April 2, 2003.


   REFERENCES
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
1. Keshavarz H, Hillis SD, Kieke BA, Marchbanks PA. Hysterectomy surveillance—United States, 1994-1999. Morb Mortal Wkly Rep CDC Surveill Summ 2002;51(SS05):18.

2. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol 2002;99: 229–34.[Abstract/Free Full Text]

3. Sills ES, Saini J, Steiner CA, McGee M, Gretz HF. Abdominal hysterectomy practice patterns in the United States. Int J Gynecol Obstet 1998;63:277–83.[Medline]

4. Thakar R, Mollison J, Manyonda IT. Total versus subtotal hysterectomy: The last great controversy in gynecological surgery? Contemp Rev Obstet Gynecol 1998;10:61–6.

5. Thakar R, Manyonda I, Robinson G, Clarkson P, Stanton S. Total versus subtotal hysterectomy: A survey of current views and practice among British gynecologists. J Obstet Gynaecol 1998;18:267–9.

6. Johns A. Supracervical versus total hysterectomy. Clin Obstet Gynecol 1997;40:903–13.[Medline]

7. Munro MG. Supracervical hysterectomy: . . . A time for appraisal. Obstet Gynecol 1997;89:133–9.[Abstract]

8. Scott JR, Sharp HT, Dodson MK, Norton PA, Warner HR. Subtotal hysterectomy in modern gynecology: A decision analysis. Am J Obstet Gynecol 1997;176: 1186–92.[Medline]

9. Jones DED, Shackelford P, Brame RG. Supracervical hysterectomy: Back to the future? Am J Obstet Gynecol 1999;180:513–5.[Medline]

10. Gimbel H, Ottesen B, Tabor A. Danish gynecologists’ opinion about hysterectomy on benign indication: Results of a survey. Acta Obstet Gynecol Scand 2002;81:1123–31.[Medline]

11. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after total versus subtotal hysterectomy. N Engl J Med 2002;347:1318–25.[Abstract/Free Full Text]

12. Howkins J, Stallworthy J. Bonney’s gynaecological surgery. 8th ed. London: Balliere Tindall, 1974.

13. Storm HH, Clemmensen IH, Manders T, Brinton LA. Supravaginal uterine amputation in Denmark 1978-1988 and risk of cancer. Gynecol Oncol 1992;45:198–201.[Medline]

14. Kovalic JJ, Grigsby PW, Perez CA, Lockett MA. Cervical stump carcinoma. Int J Radiat Oncol Biol Phys 1991;20: 933–8.[Medline]

15. Hellstrom AC, Sigurjonson T, Pettersson F. Carcinoma of the cervical stump. The radiumhemmet series 1959-1987. Treatment and prognosis. Acta Obstet Gynecol Scand 2001;80:152–7.[Medline]




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