The question of whether to retain the cervix often arises when considering the route and type of hysterectomy in benign disease. A subtotal or supracervical hysterectomy refers to the removal of the uterine corpus with retention of the cervix, whilst a total hysterectomy involves the removal of both. Traditionally, both procedures were feasible through a laparotomy or laparoscopy, although antegrade vaginal and vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery) approaches, although not common, are also practiced.

Our profession has undergone a circular evolution of this technique. Upon the introduction of the operation and prior to the 1940s, supracervical hysterectomy was most common due to the constraints in surgical technique, as well as the associated reduced morbidity (ascending infection and blood loss).¹ Subsequently, with increasingly widespread use of antibiotics and availability of blood transfusions, total (abdominal) hysterectomy became the most prevalent approach. The arrival of minimally invasive surgical techniques and reliable cervical cancer screening resulted in a slow increase in supracervical hysterectomy from the 1990s onward, and this trend is widespread across high- to middle-income countries.¹

The surgeon considers numerous factors when planning a hysterectomy: indication for the operation, size and shape of the uterus, vagina, and pelvis, accessibility and mobility of the uterus, the extent of extrauterine disease, need for concurrent procedures, availability of different technology/devices, their case load and experience, and importantly, the preference of the patient. All of this will determine the route and type of hysterectomy offered. When minimally invasive approach is being considered, the method or route of specimen removal and associated risks and benefits must also be planned as part of this discussion.

The preservation or removal of the cervix may be medically indicated and further counselling inappropriate, as is the case with malignancy. Most hysterectomies for benign causes, however, benefit from weighing up the benefits of a supracervical versus total hysterectomy and should be part of presurgical counselling and consent. In considering these options, it is useful to contemplate the following domains: neoplastic, anatomical, functional, medical conditions, and patient factors. A summary of these domains with their associated discussion points, risks, and benefits is shown in Table 1.

Table 1: Suggested indications and evidence-based decisions regarding surgery type; where no difference was found, parameter is included in both columns. LEGEND: HPV – Human Papilloma Virus; vWF – bon Willibrand Factor, VH – vaginal hysterectomy; IBS – irritable bowel syndrome; CST – cervical screening test.

Neoplastic

Traditionally, the removal of the cervix with the uterine corpus was performed for the treatment of cervical and endometrial cancer. In benign disease, before the development of the Papanicalou smear in the 1940s, removal was thought to prevent cervical cancer developing in the stump. Cervical stump disease is rare (0.11-0.2% for asymptomatic women prior to HPV screening) and on par with the incidence rate of vaginal cuff.^1,2 As it can arise both from pre-existing disease and de novo, it is important to continue cervical screening and follow guidelines in women whose cervix has been retained. Some elderly patients may be unaware that the cervix was retained, and this forms part of informed decision-making regarding ongoing surveillance.

Unfortunately, there are often significant delays in the detection of cervical stump disease due to lack of screening and assessment, and hence worse prognosis.² Subsequent cervical stump excision can be more challenging. Depending on subsequent pathology (bleeding, cancer, prolapse), vaginal, abdominal, or laparoscopic trachelectomy can be performed. In cases of bleeding from benign remnant endometrial cells, ablation of the endocervical canal and the transformation zone can be a less invasive option.

In the presence of HPV colonisation and cervical dysplasia, careful counselling needs to clarify that the removal of the cervix, whilst treating cellular changes and potentially decreasing the viral load, does not eliminate pre-existing HPV and future genital cancer risk. Following surgery, in patients with persistent high-risk of HPV subtype/s, the risk can shift to the genitoanal tract.³

For cases of endometrial hyperplasia, total hysterectomy is indicated due to the presence of endometrium in the proximal cervical canal. Patients who have hyperplasia without atypia have a very low risk of progression to endometrial cancer and, if clinically suitable, can be managed with progesterone and surveillance and avoid surgery altogether.⁴ However, hyperplasia with atypia often co-exists with early cancer and should be managed surgically with a total hysterectomy – all routes and techniques are non-inferior but all should avoid open morcellation.⁵ Preoperative workup and histopathology will guide any need for postoperative surveillance.

Anatomical

In cases of significant uterine prolapse, the connective tissues are damaged with cervical descent signalling weakness in the pelvic diaphragm, the endopelvic fascia, and the vagina, resulting in herniation through the perineum.⁶ When a vaginal hysterectomy is planned, a subtotal hysterectomy is not feasible. Abdominally, during open or laparoscopic operation, there is an option of preserving the cervix by performing a colpopexy. The choice of either option should be based on the baseline level of prolapse. Cervical preservation appears to be protective against future prolapse if there is minimal to no pre-existing prolapse,⁷ whilst when the indication for a hysterectomy is a prolapse, the retention of the cervix does not affect the rates of future (vault) descent.⁸ Most studies have inadequate follow-up to further inform decision-making in this space.

When discussing sub- versus total hysterectomy, it is advisable to consider the patients’ pre-existing risk factors for pelvic organ prolapse such as parity, BMI, and lifestyle, and counsel accordingly. Research has not identified any increased rate of surgical complications such as bladder or ureteric injury between the two procedures;⁹ however, intraoperative blood loss was higher in total hysterectomy¹⁰ and there was more postoperative pyrexia.¹¹

Conditions

One of the most frequent indications for hysterectomy is the presence of fibroids and associated heavy menstrual bleeding (HMB). The route of the operation will depend on the total fibroid numbers, their size, and location, along with other patient-specific factors. As the presence of leiomyomas contributes to HMB, the cervix is commonly removed. Exceptions to this can include the presence of cervical leiomyomas with their associated distorted anatomy. In such cases, conservation of the cervix may result in reduced risk of complications and related morbidity.

Although often not directly affecting the uterus, the presence of endometriosis and associated dysmenorrhea and pelvic pain often leads to a total hysterectomy. A 2020 study of 137 Swedish women demonstrated a significant reduction (76% compared to baseline) in severe pain in women who underwent hysterectomy over a five-year follow-up period (of any type).¹² This effect was lower (28%) for mild pain.

Unfortunately, literature is unclear whether the removal of the cervix makes any difference to subsequent symptoms. A review of 32 studies demonstrated no differences to short- or long-term outcomes or patient satisfaction in both surgical approaches;¹³ however, the data considered was heterogenous. In cases of adenomyosis alone, and co-existing endometriosis and adenomyosis, there was no difference in rates of recurrence of endometriosis, quality of life, sexual, and patient satisfaction between cervical preservation and excision.¹³

However, in cases of deep infiltrating endometriosis with significant other organ disease and/or adhesions, a total hysterectomy may protect the patient from requiring future operations and a potentially challenging trachelectomy.

HMB without concomitant diagnoses of hyperplasia, fibroids, or adenomyosis, benefits from the removal of the cervix, particularly if the patient desires amenorrhea. Cervix can be preserved if the patient is open to continuation of (normal volume) bleeding and is happy to continue cervical screening. For women with HMB and a bleeding disorder such as von Willebrand disease, total hysterectomy should be advised, as the risk of bleeding during surgery and subsequent bleeding from the cervix is higher.¹⁴ This must be balanced with evidence that supracervical hysterectomy results in less blood loss.¹⁵

Total hysterectomy is also often advised when the indication is gender dysphoria or reassignment/gender-affirming surgery. Although all options should be adequately discussed during counselling, menstrual bleeding is usually undesirable and often difficult to control with androgen hormonal therapy. As such, the removal of the cervix will provide reassurance that periods will cease. HPV status and surveillance if present also needs to be clarified as part of treatment.

Functional

Removal of the cervix disrupts several endopelvic fascial supports, including the cardinal and uterosacral ligaments which support the cervix and vagina. These mostly attach to the cervix but approximately one-third anchor the vagina at the upper paracolpium.¹ The paracervical or inferior hypogastric plexus and ganglia are intimately involved with the cardinal ligament and carry autonomic and sensory neurotransmissions from the pelvic organs, upper vagina, bladder, and proximal urethra.⁶ Sensory nerves pass primarily via the pudendal nerve, through the plexus and to the second, third, and fourth sacral nerves. Disruption of this connective fascia and the necessary dissection and reflection of the bladder during a total hysterectomy may expose these nerves to damage and potential for subsequent end organ dysfunction.

However, data on bladder, bowel, and sexual function does not support this theory: RCT of 279 women undergoing abdominal subtotal or total hysterectomy found no difference in the two groups in pelvic organ function in women at 12 months.¹¹ Further, a meta-analysis demonstrated no difference in sexual satisfaction rates at 12 months,¹⁰ and another established no difference in bladder symptoms; however found some improvement in stress urinary incontinence post total hysterectomy.⁹ Lethaby and colleagues analysed nine RCT studies with 1553 participants and found no difference in bladder, bowel, and sexual function at two- and nine-years postoperatively.¹⁵ There was little difference found in the timing of the resumption of sexual activities after subtotal hysterectomy.¹⁶

From another functional perspective, total hysterectomy, particularly if performed vaginally, can potentially result in shorter vaginal length, which, if significant, can affect sexual function.¹⁹

Patient Factors

There are several patient-related factors which should be included in decision-making regarding the type of hysterectomy chosen. Central are the patient’s wishes; some of these include goal of amenorrhea, total removal of a painful or perceived diseased (or unwanted, as is the case in gender dysphoria) organ, retention of the cervix for the integrity of the vagina, or shorter operation with a reduced downtime. This list is not exhaustive, and requests need to be considered on a case-by-case basis, with counselling tailored to medical indications as well as patient’s comorbidities. Supracervical hysterectomy may be indicated more when a shorter operation is desired.^9,11,15

Conclusion

The decision to retain or remove the cervix in benign hysterectomy must be highly individualised. Although subtotal hysterectomy involves less extensive surgery, shorter operating time, and less perioperative bleeding, it can result in cyclical bleeding and need for repeat surgery without any benefits of symptom, particularly pain alleviation.