Cervical Preservation During Hysterectomy
The cervix can be preserved during hysterectomy in select cases, but total hysterectomy with removal of the cervix is generally recommended for benign uterine disease due to better long-term outcomes and reduced risk of complications. 1
Types of Hysterectomy
- Total hysterectomy: Removal of both the uterus and cervix 2
- Supracervical/subtotal hysterectomy: Removal of the uterus while preserving the cervix 3, 4
Indications for Cervical Preservation
Appropriate Scenarios for Cervical Preservation:
Fertility preservation in early-stage cervical cancer:
- Radical trachelectomy with pelvic lymph node dissection may be performed for stage IA1 and IA2 disease in patients who wish to preserve fertility 2
- After childbearing is complete, hysterectomy can be considered for patients who had radical trachelectomy if they have chronic persistent HPV infection, persistent abnormal Pap tests, or desire this surgery 2
Technical considerations:
Contraindications to Cervical Preservation:
- History of abnormal cervical cytology 4
- Cervical involvement in endometrial cancer 2
- Small cell neuroendocrine tumors or minimal deviation adenocarcinoma 2
Evidence on Outcomes with Cervical Preservation vs. Removal
Risks of Cervical Preservation:
- Increased risk of cervical cancer (0.05 to 0.27%) 1
- Increased risk of reoperation for cervical bleeding 1
- Continued need for routine cervical cancer screening 2, 4
- Possibility of continued cyclic vaginal bleeding 4
Surgical Considerations:
- Cervical removal adds approximately 11 minutes to operative time for open abdominal procedures but does not significantly increase operative time for laparoscopic procedures 1
- Supracervical hysterectomy may be associated with less blood loss and shorter surgical time, but these differences are not clinically significant 4
Post-Operative Outcomes:
- No significant difference in short-term complications (blood transfusion, ureteral or bladder injury) between total and supracervical hysterectomy 1
- No significant difference in long-term complications (pelvic organ prolapse, sexual disorders, urinary incontinence) 1, 4
- Total hysterectomy is not associated with worse quality of life or sexual function compared to supracervical hysterectomy 4
Special Considerations
Endometrial Cancer with Cervical Involvement:
- Traditional approach was radical hysterectomy when cervix is grossly involved 2
- Recent evidence suggests:
- Type of hysterectomy (simple vs. modified vs. radical) was not an independent prognostic factor for recurrence or survival in patients with endometrial cancer with cervical involvement 2
- Postoperative radiation therapy has been identified as an independent predictor of recurrence and survival 2
- Many now advocate for simple hysterectomy with postoperative radiation therapy to decrease risk of locoregional recurrence 2
- Radical hysterectomy should still be considered for patients with bulky cervical involvement if simple hysterectomy would "cut through" the tumor 2
Post-Hysterectomy Screening:
- Women who have had a total hysterectomy with removal of the cervix do not require routine Pap tests unless the hysterectomy was performed because of cervical cancer or its precursor lesions 2
- Women with a supracervical hysterectomy must continue routine cervical cancer screening 4
Recommendations
- Strong recommendation for removal of the uterine cervix during hysterectomy for women with benign uterine disease 1
- Vaginal hysterectomy is generally considered the first choice of surgical approach for most benign indications when feasible 4
- Women should be counseled that hysterectomy is usually associated with improved quality of life, including improved sexual function, whether or not the cervix is removed 4
- Supracervical hysterectomy should not be recommended as superior for prevention of postoperative lower urinary tract symptoms 4