A randomized comparison of Total or Supracervical hysterectomy: Surgical complications and clinical outcomes

The Total or Supracervical Hysterectomy Research Group (TOSH) presents a comparison of total versus supracervical hysterectomy in 135 women from 4 different institutions. All participants were premenopausal women over 30 years of age who were planning abdominal hysterectomy for symptomatic uterine leiomyomata, abnormal uterine bleeding, or both. Women with abnormal cervical cytology or suspected malignancy were not included. Patients were randomized to undergo standard total abdominal hysterectomy (TAH) or supracervical hysterectomy (SCH) performed using the operating surgeon's customary technique. At the initial visit and every 3 months for 2 years, participants provided information on gynecologic and reproductive history, gynecologic symptoms, including bleeding, pain, pelvic or bladder pressure, low back pain, and urinary incontinence, and also quality-of-life measures. There were 67 women in the TAH group and 68 in the SCH group. Both groups were similar in clinical and demographic characteristics. Intraoperative decisions converted 3 women in the TAH group to SCH and 4 in the SCH to TAH. In addition, 2 women in the TAH group and 1 in the SCH group did not have a hysterectomy. Histopathologic examination of the surgical specimen found complex hyperplasia of the endometrium with atypia in 2 patients in the SCH group. In the TAH group, 3 patients had high-grade squamous intraepithelial lesions of the cervix and 1 had a uterine sarcoma found adjacent to a submucous leiomyomata and an adenomyosis implant. No differences were seen between the 2 groups in surgical characteristics, clinical findings, or complications. In each group, there was one death unrelated to hysterectomy. Twenty-one women in the SCH group were readmitted to the hospital a total of 29 times. Eight of these women had 10 readmissions, which were related to hysterectomy. In the TAH group, 15 patients had a total of 11 readmissions, 5 of which were related to hysterectomy in 4 patients. This difference between the 2 groups was not significant. Multivariable analysis of all factors affecting readmission found that baseline weight (before surgery) greater than 100 kg more than doubled the risk of being readmitted to the hospital for all causes (relative risk [RR], 2.18; 95% confidence interval [CI], 1.6-4.48; P = 0.034). There was a nonsignificant increased risk for readmission related to hysterectomy (RR, 2.83; 95% CI, 0.86-9.36; P = 0.088). Baseline weight greater than 100 kg was the only significant predictor for hospital readmission. After 24 months of follow up, women in both the TAH and the SCH group reported a 48% to 97% reduction in pelvic symptoms and back pain. Urinary tract symptoms and incontinence were similarly reduced, 41% to 88% in both groups. The 2 groups were similar in their use of postoperative narcotic analgesic, infection rate, pelvic pain, and reports of depression. The number of days of work missed, days spent in bed, and days of reduced activity were similar for both groups.