Introduction

Subtotal or supracervical hysterectomy was carried out at the beginning of the last century in order to reduce complications from total hysterectomy related to ureteral injuries and vaginal cuff abscess. Leaving the cervical stump, however, gave rise to different risks and problem conditions, including cancer, which could manifest several years after the original supracervical hysterectomy. For many reasons that include improvements in surgical technique and control of infection, supracervical hysterectomy subsequently became a less common surgical procedure. Recently, in an attempt to reduce perioperative morbidity associated with the laparoscopic approach and adverse effects of total hysterectomy on sexual and urinary function, it has regained popularity and has been the subject of numerous reports.

Prospective randomized trials have shown no benefits of supracervical hysterectomy and perioperative morbidity. Choosing to preserve the cervix to reduce adverse effects on sexual and urinary function is also not supported. The immediate benefit associated with supracervical hysterectomy is faster patient recovery, but no long-term benefits were found to be associated with it. At the Mayo Clinic, several studies have been published on the removal of the cervical stump after supracervical hysterectomy dating back to 1910. In 1931, Mayo and Mayo ² reported the risk of developing cervical carcinoma and the surgical technique for trachelectomy for the retained cervical stump.

Between January 1, 1910 and July 1, 1931, a total of 99 women presented to the Mayo Clinic with carcinoma of the cervical stump after subtotal hysterectomy. Carcinoma of the retained cervical stump was diagnosed within the first 2 years of supracervical hysterectomy in most women, but as late as 21 years in others. Removal of the cervix at the time of hysterectomy was recommended owing to the subsequent risk of developing cervical carcinoma. If the cervix was not removed, they recommended a cone-down of the cervix in order to prevent subsequent bleeding and reduce the risk or cervical cancer. This recommendation was made before the development of screening for cervical cancer.

Indications for trachelectomy

Welch et al. reviewed the indications for removing the cervical stump in 397 women over 15 years between 1940 and 1954. ( Table 1 ) The most common indications were prolapse and bleeding. They advocated vaginal trachelectomy as having less morbidity than the laparotomy approach.

Pratt et al. studied a total of 262 trachelectomies over 25 years between 1949 and 1973 for retained cervical stump after supracervical hysterectomy. The most common indications were prolapse and bleeding ( Table 1 ), dyspareunia, abnormal Pap smear or malignancy ( n = 52), pelvic mass or pain ( n = 47), benign cervical lesions ( n = 5), miscellaneous ( n = 6), and other malignancies ( n = 6). Of the 44 women with neoplastic conditions of the cervix, 39 had in-situ disease and five had invasive cervical carcinoma. The stage at diagnosis was as follows: stage IB ( n = 1); stage IIB, ( n = 2); stage IIA, ( n = 1); with leiomyosarcoma ( n = 1).

Hilger et al., reported a total of 335 women who underwent trachelectomy for retained cervical stump between 1974 and 2003. The most common indications for trachelectomy were prolapse and the presence of a pelvic mass. Dyspareunia was the reason in 3% of the women. In half of them, trachelectomy was carried out, on average, 26 years after the supracervical hysterectomy.

Some conclusions may be drawn from the review of the indications. The decreasing incidence of bleeding across the three time periods may reflect improvement in the surgical technique used during the supracervical hysterectomy. Prolapse of the cervical stump was the most common cause for trachelectomy in the three studies. This would suggest that supracervical hysterectomy is not effective in preventing prolapse. The fact that half of the women in the study by Hilger et al. had their trachelectomy 26 years after the supracervical hysterectomy indicates that loss of tissue elasticity is an important factor in the cause of prolapse. Cervical neoplasia, pre-invasive or invasive, persisted as a cause for trachelectomy in the three studies. One of the patients neglected to have subsequent pap smears and was diagnosed with Stage IVA cervical carcinoma. Despite irradiation, her carcinoma recurred, and was treated by pelvic exenteration. She died of her cervical malignancy. This death could have been prevented with a total instead of subtotal hysterectomy.