Methods of hysterectomy: Should women have a say?

The review by Johnson et al shows that vaginal hysterectomy outperforms (open) abdominal hysterectomy on all outcomes for which there is evidence from randomised controlled trials, and laparoscopic hysterectomy outperforms abdominal hysterectomy on all except injuries to the bladder or ureter.1 In practice, abdominal hysterectomy dominates, so Edozien in his editorial reasonably advocates more training in vaginal surgery and the development of evidence based guidelines about choice of surgical method.2

Questions must also be asked about how women should be informed about, and enabled to influence, the selection of a method for their hysterectomy.

We recently found that 25% of women surveyed before a hospital admission for hysterectomy had not been told what method they would have.3 Fewer than half had been told about the advantages or disadvantages of different methods. Women knew, or learnt as they discussed their forthcoming hysterectomy with friends, that there are different methods. The women whose gynaecologists had told them that vaginal or keyhole surgery was not feasible because of their particular pathology—for example, large fibroids—apparently accepted this. But some women whose gynaecologists did not discuss alternative methods of hysterectomy wondered whether the selection was made in their interests or their gynaecologists'. None expressed awareness that some gynaecologists only perform certain methods of hysterectomy.

Decisions between hysterectomy methods may be preference sensitive. Although the review team consider laparoscopic surgery preferable to abdominal surgery,1 some women may be more concerned to avoid higher risks of bladder or ureter injury than to obtain other benefits associated with the laparoscopic method.

Especially in the context of renewed calls for greater choice for patients about type of treatment,4 the nature and acceptability of constraints on individual choice between hysterectomy methods need careful consideration, as do the desirability and feasibility of revising consultation and referral procedures to give women more say about their surgical procedures.