Subtotal hysterectomy and possible risks of cervical and endometrial cancer: need for pre-operative counselling
Subtotal hysterectomy and possible risks of cervical and endometrial cancer: need for pre-operative counselling |
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*Fabian Imoh-Ita MBBS MRCOG, #Bika. O MBCh, **Belkumgaur FRCOG.
*Consultant in Obstetrics and Gynaecology, West Middlesex University Hospital, Isleworth, Twickenham. TW7 6AF
#Senior House Officer in Obstetrics and Gynaecology, Queen Elizabeth 11,
Welyn Garden City, Hertfordshire.
**Consultant Obstetrician and Gynaecology, Queen Elizabeth Queen Mother Hospital,
Margate, Kent.
Abstract:
Recently there has been renewed interest by gynaecologists, the media and women in sub-total hysterectomy. Sub-total hysterectomy is portrayed as being technically simpler and woman friendlier than total hysterectomy. There is therefore the risk of being pressurised to offer sub-total hysterectomy to women without fully exploring the risk factors for developing cervical stump carcinoma. Although the incidence of this is low, it is relatively more difficult to manage. Risk factors to cervical and endometrial carcinoma must be rigorously excluded before offering women subtotal hysterectomy.
Keywords:
Subtotal hysterectomy, cervical stump cancer, and endometrial cancer.
Introduction:
In the latter half of the last century gynaecologists commonly preferred total hysterectomy to sub-total hysterectomy because of the potential risk of cervical stump carcinoma with the latter. Recently however, some gynaecologists and the media have expressed renewed interest in sub-total hysterectomy.
Gynaecologists who prefer sub-total to total hysterectomy believe in the validated effectiveness of the cervical cancer-screening programme. Furthermore sub-total hysterectomy is a quicker and technically easier procedure. It is also associated with fewer complications, shorter recovery period1 and consequential reduction of overall hospital cost. It is also argued that sexual function is better preserved after sub-total hysterectomy than after total hysterectomy because the cervix contributes to vaginal lubrication during coitus and the incidence of post-operative vaginal scarring and shortening is minimal. Understandably this appeals to some women and influences their choice regarding the type of hysterectomy to which they consent. Some women prefer subtotal hysterectomy because they wish to retain some part of their womb for psychological reasons.
The major disadvantage of sub-total hysterectomy is the risk of developing squamous cell carcinoma, adenocarcinoma or endometrial carcinoma in the cervical stump. Cancer in the cervical stump is difficult to treat and it is associated with a much higher complication rate than when the uterus is present2. Although the frequency of cervical stump carcinoma is low especially in some developed countries because of the efficient screening programmes, screening for squamous cell carcinoma of the ecto-cervix has its inherent risks. Likewise, screening for cervical stump adenocarcinoma is not reliable and screening for endometrial carcinoma is not available. Cervical stump endometrial carcinoma is possible but rare. Endometrium from incompletely excised body of the uterus may give rise to endometrial carcinoma as in the reported cases of endometrial carcinoma arising from minute residual pockets of endometrium, after trans-cervical endometrial resection3.
Some gynaecologist would argue that the risk of developing cervical stump endometrial carcinoma is inconsequential. They presume that coning their excision of the uterine body into the cervical canal removes all endometrial tissue. Since most sub-total hysterectomies are performed during surgical emergencies, the removal of the entire endometrial tissue cannot always be guaranteed. Women with high-risk factors for cervical neoplasia such as persistent high-risk oncogenic human papilloma virus infection (HPV type 16, 18, 31, 33), high viral load of human immune deficiency virus4 and those with persistent inadequate or low grade cervical smear abnormalities should be adequately counselled about the risk of developing cancer of the cervical stump. This should also apply to women at risk of developing endometrial cancer. These are women with polycystic ovarian disease, obesity, diabetes mellitus, previous history of breast or colon cancer5 and those taking Tamoxifen. It is prudent to avoid sub-total hysterectomy in women with risk factors for cervical and endometrial carcinoma. Sub-total hysterectomy in such women should only be performed for strong medical indication or after detailed counselling. Intrafascial hysterectomy may be considered in women who absolutely refuse total hysterectomy for social reasons as the utero-sacral ligaments and nerves within them can be preserved6. However this procedure is yet to be validated by further trials. This caution is even more pertinent to women in countries with poor cancer screening programmes.
Conclusion:
Sub total hysterectomy has a definite place in gynaecological surgery but the pros and cons must be weighed up astutely for individual women so that it does not do more harm than good. It should not be offered heedlessly because it is simple, cheaper and in fashion. The risk of developing cervical stump cancer must always be fully investigated from history, clinical examination and laboratory investigations where appropriate before offering the procedure to a woman. All women having sub-total hysterectomy must be adequately counselled about the need to continue with cervical smear screening and early investigation for vaginal bleeding.
References:
1. Jones D.E.D, Shackeford D.P, Brame R.G: Supracervical hysterectomy: back to future? American Journal of Obstetrics and Gynaecology. 180(3 Pt 1): 513-5, 1999 March.
2. Petersen L. K, Mamsen A, Jakobsen A: Carcinoma of the cervical stump. Gynaecologic Oncology. 46(2): 199-202, 1992 August.
3. Copperman A.B, DeCherney A.H, Olive D.L: A case of endometrial cancer following ablation for dysfunctional uterine bleeding. Obstetrics and Gynaecology. 82(4 Pt 2 Suppl): 640-2, 1993 October.
4. Heard I, Tassie JM, Schmitz V, Mandeldrot L, Kazatchkine MD, Orth G: Increased risk of cervical disease among human immunodeficiency virus-infected women with severe immunosuppression and high human papillomavirus. Obstet Gynaecol 2000 Sep; 96(3): 403-9.
5. Auranen SA, Grenman SK, Makinen JI, Salami TA: Primary breast and colon cancer associated with endometrial or ovarian cancer. Ann Chir Gynaecol Suppl. 1994; 208: 5-9.
6. Slack M. C, Quinn M.J. British Journal of Obstetrics and Gynaecology, January 2003, Vol. 110, pp 83.
Correspondence to:
Dr. Fabian Imoh-Ita. 74 St Pauls Wood Hill, Orpington, Kent, England, BR5 2SU.
E-mail: fimohita@hotmail.com
©2004 Sexual Health Matters. Published Quarterly by Express
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