Cervical Retention During Hysterectomy
In standard hysterectomy for benign disease, removal of the cervix (total hysterectomy) is recommended over cervical retention (supracervical hysterectomy) due to reduced risk of future complications and need for reoperation. 1
Types of Hysterectomy and Cervical Management
Total Hysterectomy vs. Supracervical Hysterectomy
- Total hysterectomy: Removal of both uterus and cervix
- Supracervical hysterectomy: Removal of uterine body while preserving the cervix
Current Standard Practice
The French College of Obstetricians and Gynecologists (CNGOF) strongly recommends removal of the cervix during hysterectomy for benign uterine disease based on high-quality evidence 1. This represents the current standard approach in gynecologic practice.
Evidence Supporting Cervical Removal
Risk Reduction Benefits
- Cancer prevention: Cervical retention carries a 0.05-0.27% risk of future cervical cancer 1
- Reduced reoperation: Lower risk of needing additional surgery for cervical bleeding or pathology 1
- Avoids future complications: 38% of women who undergo later removal of a retained cervix experience complications, with bleeding complications being most common (26%) 2
Surgical Considerations
- Cervical removal adds only approximately 11 minutes to open abdominal hysterectomy procedures
- No significant increase in operative time when performed laparoscopically 1
- No increased prevalence of short-term complications (blood transfusion, ureteral or bladder injury) 1
Long-term Outcomes
- No significant differences in:
- Pelvic organ prolapse rates
- Sexual function
- Urinary incontinence 1
Special Circumstances for Cervical Management
Endometrial Cancer
For endometrial cancer, the standard approach is simple hysterectomy (removing the uterus and cervix) unless there is cervical involvement 3. When cervical involvement is present:
- Traditional approach: Radical hysterectomy (removing cervix, parametria, and upper vagina)
- Current evidence-based approach: Simple hysterectomy with postoperative radiation therapy is often sufficient, as:
- Radical hysterectomy has not been associated with improved prognosis in SEER analysis
- Postoperative radiation therapy has been identified as an independent predictor of recurrence and survival 3
Cervical Cancer
For cervical cancer, radical hysterectomy (including cervix removal) is standard treatment for stage IA2 disease and beyond 3.
Arguments for Cervical Retention
Some older literature has suggested potential benefits of cervical retention:
- Possible role in sexual arousal and orgasm
- Potential preservation of nerve ganglia associated with bladder and bowel function
- Shorter operative time and potentially fewer complications 4
However, more recent and higher-quality evidence contradicts these purported benefits, showing no significant differences in sexual function, urinary incontinence, or pelvic organ prolapse between total and supracervical hysterectomy 1, 5.
Practical Implications
When counseling patients about hysterectomy options:
- Explain that total hysterectomy (removing the cervix) is the standard of care for benign disease
- Discuss the risks of cervical retention, including:
- Need for continued cervical cancer screening
- Risk of future cervical pathology requiring additional surgery
- High complication rates (38%) if cervical removal is needed later 2
Conclusion
While historical practice has sometimes favored cervical retention, current high-quality evidence supports cervical removal during hysterectomy for benign disease to reduce long-term risks and complications. Randomized trials show minimal short-term surgical advantages to supracervical hysterectomy, with no long-term benefits in pelvic floor function or sexual outcomes 5.