Why the Cervix is Left During Subtotal Hysterectomy
The cervix is sometimes left during hysterectomy for benign conditions based on theoretical advantages including shorter operative time, potentially reduced surgical morbidity, and patient preference, though high-quality evidence supporting superior outcomes is lacking.
Theoretical Advantages of Supracervical Hysterectomy
Several potential benefits have been proposed for leaving the cervix intact during hysterectomy for benign disease:
Reduced operative time and blood loss: Supracervical hysterectomy may be associated with modestly shorter surgical time (approximately 11 minutes less by laparotomy, though no difference by laparoscopy) and less intraoperative blood loss, though these differences have not been found to be clinically significant 1, 2, 3.
Theoretical preservation of pelvic support: Some surgeons have advocated that retaining the cervix may better preserve bladder function, sexual function, and reduce pelvic floor prolapse 1.
Simplified surgery in complex cases: When benign conditions significantly distort cervical anatomy and complicate dissection, supracervical hysterectomy represents a prudent choice to avoid difficult dissection and reduce risk of ureteral or bladder injury 4.
What the Evidence Actually Shows
The reality is that high-quality randomized trials have failed to demonstrate meaningful clinical advantages of supracervical over total hysterectomy:
No difference in sexual function: Women can be reassured that hysterectomy is usually associated with improved quality of life and sexual function whether or not the cervix is removed 2.
No difference in urinary function: Two prospective trials (one randomized) failed to demonstrate any difference in urinary incontinence or bladder function between supracervical and total hysterectomy 1, 2.
No difference in pelvic organ prolapse: Removal of the cervix is not associated with increased prevalence of long-term complications including pelvic organ prolapse 3.
No clinically significant difference in complications: Although supracervical hysterectomy may have marginally less blood loss, cervix removal is not associated with increased short-term complications (blood transfusion, ureteral or bladder injury) or long-term complications 2, 3.
Important Disadvantages of Leaving the Cervix
Women must understand the concrete disadvantages before choosing supracervical hysterectomy:
Continued cervical cancer screening required: Women who retain their cervix must continue routine cervical cytology screening according to standard guidelines indefinitely 1, 2.
Risk of persistent cyclic bleeding: Women should be counseled that they may continue experiencing cyclic vaginal bleeding following supracervical hysterectomy 2.
Increased cervical cancer risk: Conservation of the cervix is associated with an increased risk of cervical cancer (0.05 to 0.27%) 3.
Risk of reoperation: Cervical retention is associated with an increased risk of reoperation for cervical bleeding or other cervical pathology 3.
Current Guideline Recommendations
The French College of Gynecologists and Obstetricians provides the strongest and most recent recommendation:
Removal of the uterine cervix is recommended for hysterectomy in women with benign uterine disease (STRONG recommendation, GRADE 1-), as the risk-benefit balance favors total hysterectomy 3.
Vaginal hysterectomy is generally considered the first choice of surgical approach for most benign indications, as it is associated with lower morbidity, fewer complications, and faster recovery than abdominal approaches 2.
Critical Clinical Pitfalls to Avoid
Do not recommend supracervical hysterectomy as superior for preventing urinary symptoms or sexual dysfunction, as evidence does not support these claims 2.
Women with current or significant history of abnormal cervical cytology should be counseled on the advantages of total hysterectomy over supracervical hysterectomy to eliminate future cervical cancer risk 2.
Ensure patients understand they will need lifelong cervical screening if the cervix is retained, which eliminates one of the potential benefits of hysterectomy (no further need for Pap smears) 1, 2.
When Supracervical Hysterectomy May Be Appropriate
Despite the lack of proven advantages, supracervical hysterectomy remains a reasonable option in specific circumstances:
Severe pelvic adhesions or distorted anatomy where cervical dissection would significantly increase operative risk 4.
Patient preference after thorough counseling about the lack of proven benefits and the concrete disadvantages, particularly the need for continued screening 2.
As part of laparoscopic approach when it may facilitate a minimally invasive approach in selected cases 4.