{"paper_id":"13f9d01c-ba3d-4403-86cd-8338aa66b613","body_text":"Abstract\n!\nBackground: Official guideline “indications and\nmethods of hysterectomy ” to assign indications\nfor the different methods published and coordi-\nnated by the German Society of Gynecology and\nObstetrics (DGGG), the Austrian Society of Gyne-\ncology and Obstetrics (OEGGG) and the Swiss So-\nciety of Gynecology and Obstetrics (SGGG). Be-\nsides vaginal and abdominal hysterectomy, three\nadditional techniques have been implemented\ndue to the introduction of laparoscopy. Organ-\nsparing alternatives were also integrated.\nMethods: The guideline group consisted of 26 ex-\nperts from Germany, Austria and Switzerland.\nRecommendations were developed using a struc-\ntured consensus process and independent mod-\neration. A systematic literature search and quality\nappraisal of benefits and harms of the therapeutic\nalternatives for symptomatic fibroids, dysfunc-\ntional bleeding and adenomyosis was done\nthrough MEDLINE up to 6/2014 focusing on sys-\ntematic reviews and meta-analysis.\nResults: All types of hysterectomy led in studies\nto high rates of patient satisfaction. If possible,\nvaginal instead of abdominal hysterectomy\nshould preferably be done. If a vaginal hysterec-\ntomy is not feasible, the possibility of a laparo-\nscopic hysterectomy should be considered. An ab-\ndominal hysterectomy should only be done with\na special indication. Organ-sparing interventions\nalso led to high patient satisfaction rates, but con-\ntain the risk of symptom recurrence.\nConclusion: As an aim, patients should be en-\nabled to choose that therapeutic intervention for\ntheir benign disease of the uterus that convenes\nbest to them and their personal life situation.\nZusammenfassung\n!\nHintergrund: Offizielle Leitlinie, publiziert und\nkoordiniert von der Deutschen Gesellschaft für\nGynäkologie und Geburtshilfe (DGGG), der Öster-\nreichischen Gesellschaft für Gynäkologie und Ge-\nburtshilfe (OEGGG) und der Schweizerischen\nGesellschaft für Gynäkologie und Geburtshilfe\n(SGGG). Durch die Einführung laparoskopischer\nOperationen wurde die vaginale und abdominale\nHysterektomie um 3 weitere Techniken ergänzt.\nUm die Indikationsfelder abzugrenzen, wurde die\nLeitlinie „Indikation und Methodik der Hyster-\nektomie bei benignen Erkrankungen“ initiiert. Or-\nganerhaltende Therapiealternativen wurden\nebenfalls integriert.\nMethode: Die Leitlinie wurde durch ein reprä-\nsentatives Gremium von 26 Experten aus\nDeutschland, Österreich und der Schweiz unter\nstrukturierter unabhängiger Moderation im Kon-\nsens erstellt. Die systematische Literatursuche\nund ‑bewertung zu Nutzen und Schaden der The-\nrapiealternativen bei symptomatischem Uterus\nmyomatosus, funktionellen Blutungsstörungen\nund Adenomyosis sowie ein Vergleich der Hyster-\nektomieverfahren erfolgte bis 06/2014 in der Da-\ntenbank MEDLINE mit Fokus auf aggregierter Evi-\ndenz.\nErgebnisse: Alle Formen der Hysterektomie sind\nin Studien mit einer hohen Zufriedenheit der Pa-\ntientinnen verbunden. Der vaginalen Hysterekto-\nmie soll gegenüber der abdominellen, wenn mög-\nlich, der Vorzug gegeben werden. Ist die vaginale\nHysterektomie nicht möglich, sollte die Möglich-\nkeit einer laparoskopischen Hysterektomie ge-\nprüft werden. Die abdominale Hysterektomie\nsollte nur bei gesonderter Indikation durch-\ngeführt werden. Für die organerhaltenden Alter-\nnativen wurde ebenfalls ein hoher Zufrieden-\nheitsgrad festgestellt, allerdings können bei Belas-\nsen des Uterus Rezidive auftreten.\nIndications and Route of Hysterectomy for Benign Diseases.\nGuideline of the DGGG, OEGGG and SGGG\n(S3 Level, AWMF Registry No. 015/070, April 2015)\nIndikation und Methodik der Hysterektomie bei benignen Erkrankungen.\nLeitlinie der DGGG, OEGGG und SGGG (S3-Level, AWMF-Registernummer 015/070, April 2015)\nAuthors K. J. Neis 1, W. Zubke 2, T. Römer 3, K. Schwerdtfeger 4, T. Schollmeyer †5, S. Rimbach 6, B. Holthaus 7, E. Solomayer 1,\nB. Bojahr 8,F .N e i s9, C. Reisenauer 9, B. Gabriel 10, H. Dieterich 11, I. B. Runnenbaum 12, W. Kleine 13,A .S t r a u s s14,\nM. Menton 15, I. Mylonas 16, M. David 17, L-C. Horn 18,D .S c h m i d t19,P .G a ß20, A. T. Teichmann 21, P. Brandner22,\nW. Stummvoll †23, A. Kuhn 24, M. Müller 24, M. Fehr 25, K. Tamussino 26\nAffiliations The affiliations are listed at the end of the article.\nKey words\nl\" guideline\nl\" hysterectomy\nl\" uterine myomas\nl\" bleeding disorders\nl\" endometriosis\nSchlüsselwörter\nl\" Leitlinie\nl\" Hysterektomie\nl\" Uterus myomatosus\nl\" Blutungsstörungen\nl\" Endometriose\nBibliography\nDOI http://dx.doi.org/\n10.1055/s-0042-104288\nGeburtsh Frauenheilk 2016; 76:\n350–364 © Georg Thieme\nVerlag KG Stuttgart · New York ·\nISSN 0016‑5751\nCorrespondence\nProf. Dr. Klaus Neis\nDepartment of Gynecology,\nObstetrics and Reproductive\nMedicine of the University\nHospital of the Saarland,\nHomburg/Saar\nFrauenärzte am Staden\nBismarckstraße 39–41\n66121 Saarbrücken\nkjneis@gyn-saar.de\ngynécologie \nsuisse\n350\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGebFra Science\nDeutsche Version unter:\nwww.thieme-connect.de/\nejournals/gebfra\n\n\nI Guideline Information\nGuidelines Program of the DGGG, OEGGG and SGGG. Information\non this topic is provided at the end of the guideline.\nCitation format\nIndications and route of hysterectomy for benign diseases.\nGuideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF\nRegistry No. 015/070, April 2015). Geburtsh Frauenheilk 2016;\n76: 350– 364\nGuideline documents\nThe complete long version and a summary of the conflicts of in-\nterest of all of the authors in the Guideline methods report are\navailable on the AWMF website:\nhttp://www.awmf.org/leitlinien/detail/ll/015-070.html\nAuthors\nSee l\" Table 1.\nSchlussfolgerung: Ziel der Aufklärung ist, die Patientin in die\nLage zu versetzen, unter den Therapieoptionen für benigne Ute-\nruserkrankungen diejenige herauszufinden, die am besten zu ihr\nund ihrer Lebenssituation passt.\nTable 1 Authors.\nAuthor\nMandate holder\nDGGG working group/professional association/organization/society\nCoordinating lead authors:\nProf. Dr. med. K. J. Neis1, 3 German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe [DGGG])\nProf. Dr. med. K. Schwerdtfeger1 AWMF Guideline consultant\nOther participating authors contributing to the guideline:\nDr. med. W. Zubke\n2, 3 German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe [DGGG])\nProf. Dr. med. K. Tamussino2, 3 Austrian Society of Gynecology and Obstetrics (Österreichische Gesellschaft für Gynäkologie und Geburtshilfe [OEGGG])\nPrim. Dr. med. W. Stummvoll † Austrian Society of Gynecology and Obstetrics (Österreichische Gesellschaft für Gynäkologie und Geburtshilfe [OEGGG])\nPD Dr. med. M. Fehr2 Swiss Society of Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe [SGGG])\nProf. Dr. med. A. Kuhn3 Swiss Society of Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe [SGGG])\nProf. Dr. med. M. Müller Swiss Society of Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe [SGGG])\nProf. Dr. med. B. Bojahr Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE])\nPD Dr. med. S. Rimbach Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE])\nProf. Dr. med. T. Römer\n2, 3 Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE])\nProf. Dr. med. E. Solomayer3 Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE])\nDr. med. T. Schollmeyer † Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE])\nDr. med. B. Holthaus Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE])\nDr. med. F. Neis\n3 Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE])\nProf. Dr. med. B. Gabriel Working Group for Urogynecology and Reconstructive Pelvic Surgery (Arbeitsgemeinschaft für Urogynäkologie\nund plastische Beckenbodenrekonstruktion [AGUB])\nProf. Dr. med. C. Reisenauer3 Working Group for Urogynecology and Reconstructive Pelvic Surgery (Arbeitsgemeinschaft für Urogynäkologie\nund plastische Beckenbodenrekonstruktion [AGUB])\nDr. med. H. Dieterich Working Group for Esthetic, Plastic and Reconstructive Surgery in Gynecology (Arbeitsgemeinschaft für ästhetische, plastis che\nund wiederherstellende Operationsverfahren in der Gynäkologie [AWOGyn])\nProf. Dr. med. I. B. Runnenbaum3 Working Group Gynecologic Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie [AGO])\nProf. Dr. med. W. Kleine Working Group Gynecologic Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie [AGO])\nProf. Dr. med. A. Strauss3 Working Group for Ultrasound Diagnosis in Gynecology and Obstetrics (Arbeitsgemeinschaft für Ultraschalldiagnostik\nin Gynäkologie und Geburtshilfe [ARGUS])\nProf. Dr. med. M. Menton3 Committee on Cervical Pathology and Colposcopy (Arbeitsgemeinschaft Zervixpathologie & Kolposkopie [AGCPC])\nProf. Dr. med. I. Mylonas3 Working Group for Infectious Diseases and Infection Immunology (Arbeitsgemeinschaft Infektiologie und Infektions-\nimmunologie ([AGII])\nProf. Dr. M. David3 German Society for Psychosomatic Gynecology and Obstetrics (Deutsche Gesellschaft für Psychosomatische Frauenheilkunde\nund Geburtshilfe [DGPFG])\nProf. Dr. med. L-C. Horn German Society of Pathology (Deutsche Gesellschaft für Pathologie [DGP])\nFederal Association of Pathologists (Berufsverband Deutsche Pathologen [BDP])\nProf. Dr. med. D. Schmidt German Society of Pathology (Deutsche Gesellschaft für Pathologie [DGP])\nFederal Association of Pathologists (Berufsverband Deutsche Pathologen [BDP])\nProf. Dr. med. A. T. Teichmann Association of Head Physicians of Gynecological and Obstetric Hospitals (Bundesarbeitsgemeinschaft Leitender Ärzt innen\nund Ärzte in der Frauenheilkunde und Geburtshilfe [BLFG])\nDr. med. P . Brandner3 Federal Association of Gynecologists (Bundesverband der Frauenärzte e. V. [BVF])\nDr. M. Nothacker4 AWMF Guideline consultant\n1 methodological support, drafting of the guideline report, 2 member of the steering committee, 3 participant in the nominal group process entitled to vote,\n4 drafting of the evidence report\n351\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGuideline\n\n\nAbbreviations\nAGCPC Committee on Cervical Pathology and Colposcopy\nAGE Working Group for Gynecological Endoscopy\nAGII Working Group for Infectious Diseases and Infection\nImmunology\nAGO Working Group Gynecologic Oncology\nAGUB Working Group for Urogynecology\nand Reconstructive Pelvic Surgery\nAIS adenocarcinoma in situ\nARGUS Working Group for Ultrasound Diagnosis\nin Gynecology and Obstetrics\nAWMF Association of the Scientific Medical Societies\nin Germany\nBVF Federal Association of Gynecologists\nBLFG Association of Head Physicians of Gynecological\nand Obstetric Hospitals\nCIN cervical intraepithelial neoplasia\nDGPFG German Society for Psychosomatic Gynecology\nand Obstetrics\nDGGG German Society of Gynecology and Obstetrics\nDGP German Society of Pathology\nETC European Training Centre for Gynecologic Endoscopy\nGnRH gonadotropin releasing hormone\nGR Grade of recommendation\nHE hysterectomy\nHPV human papilloma virus\nIUS intrauterine system\nLASH laparoscopically assisted supracervical hysterectomy\nLAVH laparoscopically assisted vaginal hysterectomy\nLoE Level of evidence\nOEGGG Austrian Society of Gynecology and Obstetrics\nSGGG Swiss Society of Gynecology and Obstetrics\nTLH total laparoscopic hysterectomy\nII Using this Guideline\nPurpose and objectives\nThis guideline concerns hysterectomy performed in patients with\nbenign diseases. It aims to examine the entire range of surgical\nprocedures as well as the associated context in order to permit\noptimal treatment of women in each case. The guideline presents\nand evaluates the individual indication areas, describes the hys-\nterectomy routes, evaluates the advantages and disadvantages of\nindividual surgical techniques and presents possible alternatives.\nThe guideline aims to provide a basis that women can use to ob-\ntain in-depth information in order to make a decision about the\ntreatment plan in consultation with their doctor based on their\nknowledge of the advantages and disadvantages of the specific\nprocedure and of the effects of the operation on their quality of\nlife. In these times of increasing cost pressure in the health care\nsystem, it is also essential to include this aspect in the considera-\ntions.\nTargeted patients\nPatients with an equivocal indication for hysterectomy and pa-\ntients who have undergone a hysterectomy.\nTarget audience\nThe guideline addresses members of the health care profession\ninvolved in performing this surgical procedure. A medical back-\nground is required to understand this guideline.\nThis guideline is aimed at the following groups of people:\n\" gynecologists in private practice\n\" gynecologists working in a clinical setting\n\" nursing professionals\n\" the cooperating partners of the medical profession (e.g. health\ncare professionals, payers)\n\" the patients concerned and their personal setting (partners,\netc.)\n\" the general public, in order to provide it with information\nabout sound medical approaches\nPeriod of validity\nThe validity of this guideline was confirmed by the chairpersons/\nheads of the participating medical societies/organizations/asso-\nciations and by the head of the DGGG and the DGGG Guideline\nCommission in April 2015, thereby also confirming the entire\ncontents of the guideline. This guideline is valid until April 30,\n2020. This period of validity was estimated based on the contents\nof the guideline. If need be, the guideline can be updated before it\nhas expired; if the guideline is still considered to represent the\ncurrent state of knowledge, its period of validity can be extended.\nIII Guideline\n1 Methodology\n1.1 Principles\nThe methodology for the compilation of this guideline is pre-\nscribed by the classification assigned to the guideline. The AWMF\nGuidance Manual and Rules for Guideline Development (Version\n1.0) sets out the rules for classifying guidelines. Guidelines are\ndifferentiated into lowest (S1), moderate (S2) and highest (S3)\nclass. The lowest class of guideline is defined as consisting of a\nset of recommendations for action compiled by a non-represen-\ntative group of experts. In 2004 the S2 class was divided into two\nsubclasses: S2e (evidence-based) and S2k (consensus-based). The\nhighest class (S3) combines both approaches.\nThis guideline is classified as S3.\n1.2 Literature search\nThe following literature databases were searched:\n\" Cochrane Menstrual Disorders and Subfertility Group special-\nized register of controlled trials\n\" Central\n\" MEDLINE\n\" Embase\n\" Biological Abstracts\n\" The National Research Register\nThe following keywords were used for the search:\n\" hysterectomy CRT\n\" hysterectomy\n\" vaginal\n\" abdominal\n\" LA VH\n\" LASH\n\" TLH\n\" myoma\n\" endometriosis\n\" adenomyosis\n\" descensus\n\" incontinence\n352\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGebFra Science\n\n\n\" complications\n\" quality of life\nThe search encompassed the period from January 1990 to No-\nvember 2011. In addition, MEDLINE was specifically searched\nwith regard to certain questions.\nIn order to achieve a transparent and up-to-date evidence base,\nan updated literature search was performed in MEDLINE (via\nPubMed) in 2013– 2014 on the following topics:\n\" comparison of hysterectomy routes\n\" comparison of hysterectomy to uterine artery embolization or\nmyomectomy for symptomatic uterine fibroids\n\" comparison of hysterectomy and drug therapy for uterine fib-\nroids, dysfunctional menstrual disorders or adenomyosis.\nThe results of the literature search were included in the current\nversion of the guideline.\n1.3 Evidence tables\n1.3.1 Evidence grading based on the Oxford Centre\nfor Evidence-Based Medicine levels of evidence\nTo evaluate the evidence (levels 1 to 5), the Oxford Centre for Evi-\ndence-Based Medicine classification system was used in its most\nrecent version published in 2009 as Level of Evidence (LoE).\n1.4 Recommendation grading\nPure evidence grading of a guideline at S2e/S3 level based on the\nOxford classification can be translated into a grade of recommen-\ndation (GR) for a guideline. This symbolic recommendation level\nis divided into three gradations with various degrees of linguistic\nexpression (l\n\" Table 2).\nThe classification of “Recommendations” presented above corre-\nsponds to both the evaluation of evidence and the clinical rele-\nvance of the studies on which they are based and their scope/fac-\ntors not listed in the grading of the evidence, such as the selection\nof patient cohort, intention-to-treat or per-protocol outcome\nanalyses, medical or ethical action toward the patient, country-\nspecific applicability, etc. Conversely, a strong, moderate or weak\nlevel of evidence can lead to strong, regular or open recommen-\ndations in a related linear fashion. The only level that permits\nboth an upward and downward classification is the moderate\nevidence level, in which a translation into level A or level 0 is pos-\nsible. In special exceptional cases, converting the highest evi-\ndence level into the weakest/an open recommendation or vice\nversa must be explained in the background text.\n\" Strong evidence level → Grade A or Grade B recommendation\n\" Moderate evidence level → Grade A or Grade B or Grade 0 rec-\nommendation\n\" Weak evidence level → Grade B or Grade 0 recommendation\n1.5 Statements\nIf statements by specialists are included in this guideline that are\nnot intended as recommendations for action, but rather simply\nfor the purpose of presentation, these are referred to as “state-\nments”. For these statements, it is not possible to indicate evi-\ndence levels.\n1.6 Consensus strength\nAs part of a structured consensus agreement process (S2k/S3 lev-\nel), the eligible participants at the meeting agree on the state-\nments and recommendations that were drawn up. During this\nprocess, significant modifications to the wording may occur. Sub-\nsequently, the consensus strength is determined based on the\nnumber of participants ( l\n\" Table 3).\n1.7 Expert consensus\nAs the name suggests, “expert consensus” refers to consensus de-\ncision specifically for recommendations/statements without a\nprior systematic literature search (S2k) or based on the missing\nevidence (S2e/S3). The term “expert consensus (EC) ” to be used\nis synonymous with terms from other guidelines such as “good\nclinical practice (GCP) ” or “clinical consensus point (CCP) ”. The\nrecommendation strength is graded similarly to the aforemen-\ntioned classification without the use of the symbols and is ex-\npressed in purely semantic terms ( “must”/“must not ” or\n“should”/“should not” or “may”/“does not need to ”).\n2 Introduction\nAll of the sections below are excerpts from the long version of the\nguideline and do not claim to be complete. Only the sections of\nthe long version are mentioned that contain consensus- and/or\nevidence-based statements or recommendations. Sections with-\nout these particulars are described briefly at most.\nTo obtain more information (background texts, additional litera-\nture citations) on existing sections or sections not listed here,\nplease download the long version (see Guideline documents).\n3 Indications and contraindications\n3.1 Indications\nCommon indications for performing hysterectomy for benign\ndiseases include the following: uterine fibroids, menstrual disor-\nders, adenomyosis of the uterus, endometriosis, uterine prolapse\nand precancerous lesions of the endometrium and the cervix.\nThe numbers in Germany were as follows in 2012: uterine fib-\nroids: 60.7 %, prolapse: 27.9 %, menstrual problems: 25.2 %, hy-\nperplasia and atypia of the endometrium or cervix: 2.9, and en-\ndometriosis: 15.1 % of cases [1].\nTable 2 Grading of recommendations.\nSymbols Description of binding nature Expression\nA Strong recommendation with\nhighly binding character\nmust (soll)/\nmust not (soll nicht)\nB Regular recommendation with\nmoderately binding character\nshould (sollte)/\nshould not (sollte nicht)\n0 Open recommendation with\nlimited binding character\nmay (kann)/\ndoes not need to\n(kann nicht)\nTable 3 Classification of consensus strength.\nSymbol Consensus strength Agreement in percent\n+++ Strong consensus Agreement of\n> 95 % of the participants\n++ Consensus Agreement of\n>7 5–95 % of the participants\n+ Majority agreement Agreement of\n>5 0–75 % of the participants\n– No consensus Agreement of\n< 50 % of the participants\n353\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGuideline\n\n\nDue to the comorbidities, a total of nearly 130 % is reached. This\nalso reflects clinical reality, in which the histologically ascertain-\nable findings of uterine fibroids, adenomyosis and endometriosis\noften coincide. The clinical picture of “menstrual problems” as an\numbrella term encompasses hypermenorrhea, dysmenorrhea\nand dyspareunia. For this reason, it is often difficult to list and\ncode a single diagnosis as the indication for hysterectomy. This\noverlapping also means that experts may disagree about the\ntreatment plan to be used in a particular case. Thus, when indi-\ncating surgery for these conditions, personal experience, espe-\ncially the mastery of a certain surgical technique or with the use\nof alternatives, plays a significantly greater role than for cancer,\nfor example, for which treatment is based on a single hard diag-\nnosis.\nDue to this special situation, it is particular important to inform\nthe patient about the range of treatment options, about the rec-\nommended procedure, the associated risks and to clearly point\nout the advantages and disadvantages of each surgical technique\nthat can be expected and if the merits of techniques “compete\nwith” each other.\nUltimately, the decision as to whether hysterectomy is indicated,\nas well as on using alternative methods, must be made by an in-\nformed patient along with her attending physician. For this rea-\nson, the term “informed consent and shared decision-making ”\nhas become established.\n3.2 Hysterectomy for uterine fibroids\nConsensus-based recommendation 3.E1\nFor suspected symptomatic uterine fibroids, the first step is to\nclarify whether the symptoms are actually caused by uterine\nfibroids. (expert consensus)\nConsensus strength (+++)\nConsensus-based recommendation 3.E2\nIf the symptoms are caused by fibroids, depending on the pa-\ntientʼs life circumstances, the treatment decision must be made\ntogether with the patient. (expert consensus)\nConsensus strength (+++)\nConsensus-based recommendation 3.E3\nHysterectomy may be performed in the case of symptomatic\nuterine fibroids, if fertility is no longer desired, if treatment alter-\nnatives have failed and/or as requested by the patient. (expert\nconsensus)\nConsensus strength (+++)\nEvidence-based statement 3.S1\nFor preoperatively anemic patients with uterine fibroids, drug\ntherapy with GnRH analogues or Ulipristal may be indicated\nprior to hysterectomy. (LoE\nOxford 2009 1a [GnRH analogues], 1b\n[Ulipristal])\nConsensus strength (+++)\nLiterature: GnRH analogues [2, 3] and Ulipristal [4, 5]\n3.3 Dysfunctional uterine bleeding\nConsensus-based recommendation 3.E4\nFor abnormal uterine bleeding, premalignant or malignant le-\nsions must be excluded prior to further treatment. (expert con-\nsensus)\nConsensus strength (+++)\nEvidence-based statement 3.S2\nIf hormone therapy has failed and fertility is no longer desired,\nendometrial ablation and hysterectomy is a treatment option.\n(LoE\nOxford 2009 1a)\nConsensus strength (+++)\nLiterature: [6]\nConsensus-based recommendation 3.E5\nIf endometrial ablation has failed, a hysterectomy must be per-\nformed. (expert consensus)\nConsensus strength (+++)\n3.4 Endometriosis/adenomyosis\nEvidence-based recommendation 3.E6\nTo confirm the diagnosis of adenomyosis/endometriosis, a de-\ntailed history and an ultrasound examination should be per-\nformed. (LoE\nOxford 2009 1b, GR A)\nConsensus strength (+++)\nLiterature: [7]\nConsensus-based recommendation 3.E7\nFor suspected endometriosis, laparoscopy should also be per-\nformed. (expert consensus)\nConsensus strength (+++)\nLiterature: Expert consensus based on S2k Guideline for the Diag-\nnosis and Treatment of Endometriosis [8]\nConsensus-based recommendation 3.E8\nIf the primary desire to have a hysterectomy stems from the pa-\ntient herself, she must receive detailed information about treat-\nment alternatives and their side effects and success rates. (expert\nconsensus)\nConsensus strength (+++)\nConsensus-based recommendation 3.E9\nIf hormone therapy has failed and fertility is no longer desired, a\nhysterectomy should be performed. (expert consensus)\nConsensus strength (+++)\nConsensus-based statement 3.S3\nFor deep infiltrating endometriosis, a hysterectomy may be indi-\ncated in the overall concept of complete resection. (expert con-\nsensus)\nConsensus strength (+++)\nLiterature: Expert consensus based on S2k Guideline for the Diag-\nnosis and Treatment of Endometriosis [8]\n3.5 and 3.6 Cytological suspicion of endometrial\nand glandular precancers\nConsensus-based recommendation 3.E10\nMicroscopically confirmed CIN alone, regardless of severity, is not\nan indication for hysterectomy.\nIn the case of persistent HPV detection after conization alone,\nhysterectomy must not be performed.\nIf there is a cytological or microscopic diagnosis of an adenocarci-\nnoma in situ (AIS) of the cervix, conization with endocervical cu-\nrettage of the high cervical canal must be performed (not a pri-\nmary hysterectomy) in order to rule out an invasive adenocarci-\nnoma.\n354\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGebFra Science\n\n\nIf there is a cytological or microscopic diagnosis of an adenocarci-\nnoma in situ (AIS) of the cervix, a primary hysterectomy must not\nbe performed in order to rule out an invasive adenocarcinoma.\nInstead, conization with endocervical curettage of the high cervi-\ncal canal must be performed.\nHysterectomy may be performed after conization in the case of\nresidual recurrent CIN 2/3 or glandular neoplasia located in the\nlow cervical canal. (expert consensus)\nConsensus strength (+++)\nLiterature: These recommendations were adopted in the expert\nconsensus based on the S2 Guidelines for HPV infection/pre-inva-\nsive lesions of the female genitals: Prevention, Diagnosis and\nTreatment [9].\n3.7 Atypical endometrial hyperplasia in the histology\nof the aspiration or of the curettage material\nConsensus-based recommendation 3.E11\nFor atypical endometrial hyperplasia in women no longer desir-\ning fertility, hysterectomy must be performed. (expert consen-\nsus)\nConsensus strength (+++)\n3.8 Prolapse\nConsensus-based statement 3.S4\nThe uterus may be retained during surgery for uterine prolapse.\n(expert consensus)\nConsensus strength (+++)\nLiterature: Expert consensus based on the Guidelines for diag-\nnosing and treating uterine prolapse [10]\nConsensus-based recommendation 3.E12\nIf the uterus is retained, the presence of a malignant tumor\nshould be excluded. (expert consensus)\nConsensus strength (+++)\n3.9 Urinary incontinence and hysterectomy\nEvidence-based recommendation 3.E13\nHysterectomy for incontinence problems must be separately in-\ndicated. (LoE\nOxford 2009 2–3, GR A)\nConsensus strength (+++)\nLiterature: [11]\n3.10 Infections\nConsensus-based statement 3.S5\nTo treat an infectious disease of the internal genitals, hysterec-\ntomy may be indicated in certain circumstances. (expert consen-\nsus)\nConsensus strength (+++)\n3.11 Chronic pelvic pain\nConsensus-based recommendation 3.E14\nLaparoscopy should be performed before performing a hysterec-\ntomy for chronic pelvic pain. (expert consensus)\nConsensus strength (++)\nLiterature: Expert consensus based on the Guidelines for diag-\nnosing chronic pelvic pain in women [12]\nEvidence-based recommendation 3.E15\nWhen indicating hysterectomy for chronic pelvic pain, the deci-\nsion must be made in cooperation with the patient based on in-\nterdisciplinary findings and the patient must be informed about\nthe high failure rate. (LoE\nOxford 2009 2a−,G RA )\nConsensus strength (++)\nLiterature: [13, 14]\n3.12 Elective hysterectomy\nConsensus-based recommendation 3.E16\nA hysterectomy that is not medically indicated to be undertaken\nonly at the patient ʼs request should not be performed. (expert\nconsensus)\nConsensus strength (+++)\n3.13 Emergency hysterectomy (nonpuerperal)\nConsensus-based statement 3.S6\nIn rare cases, a nonpuerperal emergency hysterectomy is indi-\ncated (trauma, coagulation disorder, bleeding, infection). (expert\nconsensus)\nConsensus strength (++)\n4 Alternatives to hysterectomy\n4.1 Uterine fibroids\nWhen choosing an alternative to hysterectomy, the effectiveness\nand safety of the selected treatment method and the risk of fi-\nbroid recurrence should be weighed against the (potential) ad-\nvantages of retaining the uterus (lower morbidity and retained\nfertility). In the end, rare complications may necessitate the ac-\ntually unwanted hysterectomy [15].\nConsensus-based recommendation 4.E17\nPatients must be informed about the individual success and fail-\nure rates related to the various methods of fibroid treatment. (ex-\npert consensus)\nConsensus strength (+++)\n4.2 Menstrual disorders\nA number of reasons are responsible for menstrual disorders.\nAround 50 % of menstrual disorders have organic causes. These\ncases require causal treatment such as hysteroscopic polyp and\nfibroid resection (see also Uterine fibroids) or treatment of ad-\nenomyosis or endometrial hyperplasia. If organic causes have\nbeen ruled out, intermenstrual and dysfunctional bleeding can\ngenerally be treated with hormones, primarily progestogens,\nand in some cases, also estrogens. The primary indications for\nhysterectomy are refractory hypermenorrhea and menorrhagia.\nBefore resorting to hysterectomy, the patient should receive in-\ndepth information about the wide range of proven alternatives.\nEvidence-based recommendation 4.E18\nPatients must be informed about the individual success and fail-\nure rates related to the various methods of menstrual disorder\ntreatment. (LoE\nOxford 2009 1b [LNG-IUS], 1a [endometrial ablation],\nGR A)\nConsensus strength (+++)\nLiterature: LNG‑IUS [16, 17] and endometrial ablation [18]\n355\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGuideline\n\n\n5 Information and consent\nPreoperative information and consent includes the following:\n\" the indication and objective of the procedure including an as-\nsessment of the probability of success\n\" presentation of options for treatment/methods, including non-\nsurgical alternatives\n\" explanation of the preferred method\n\" description of procedure-related risks and typical complica-\ntions, including their sequelae\n\" information about patient behavior before and after the proce-\ndure.\nConsensus-based statement 5.S7\nThe nature, scope, time and form of information and consent are\nbased on the patient ʼs individual situation, the legal provisions\nand current case rulings. Treatment options, side effects and\nprobability of success must be presented. (expert consensus)\nConsensus strength (+++)\n6 Perioperative management\nHysterectomy is a procedure that generally involves the same\nsteps regardless of the indication. For this reason, for quality-re-\nlated (and forensic) reasons, every hospital is advised to develop\nstandards for perioperative management based on the current\nevidence. Perioperative checklists are recommended to prevent\nerrors and ensure patient safety [19 – 24].\n6.1 Preoperative management\nConsensus-based recommendation 5.E19\nFor patients with known or suspected organic or systemic disor-\nders, the relevant laboratory parameters (e.g. for patients with\nbleeding disorders) must be determined. (expert consensus)\nConsensus strength (+++)\n6.2 Intraoperative management\nEvidence-based recommendation 6.E20\nProphylactic antibiotics must be administered prior to hysterec-\ntomy. (LoE\nOxford 2009 1a, GR A)\nConsensus strength (+++)\nLiterature: [25]\n6.3 Postoperative management\nEvidence-based recommendation 6.E21\nPerioperatively, risk-adapted thromboembolic prophylaxis must\nbe administered. (LoE\nOxford 2009 1a, GR A)\nConsensus strength (+++)\nLiterature: [26]\n7 Surgical techniques\n7.1 Vaginal hysterectomy\nIn addition to the general indication for a hysterectomy, the use\nof a vaginal approach involves the following special aspects:\n\" To ensure that the approach is reliable, the uterus must be suf-\nficiently mobile. In general, with the patient under anesthesia,\nit should be possible to pull the portio to at least the mid-vagi-\nna. The vagina must be sufficiently broad and elastic for the\nsurgery to be performed safely. In case of doubt, it may be help-\nful to perform the pelvic examination under anesthesia by\npulling on the portio using bullet forceps.\n\" In the case of suspected extrauterine pathology prior to sur-\ngery, for instance, in the adnexa, a laparoscopically assisted or\nabdominal approach should be favored.\n\" A vaginal approach is therefore particularly suitable for benign\nuterine diseases such as uterine prolapse. For nulliparous\nwomen and postmenopausal patients with atrophied vaginas\nand patients with long, narrow vaginas (obese patients) and\npatients with massively enlarged uteruses, the vaginal ap-\nproach has its limits.\n\" However, the size of the uterus can be overcome by using mor-\ncellation or hemisection. As a rule of thumb, again depending\non the sufficient breadth of access and the mobility of the or-\ngan, vaginal hysterectomy can be performed for a uterine size\nof around a 12-week pregnancy or a uterine weight of around\n250 to 300 g. This corresponds to an average diameter of the\nuterine body of around 8 to 10 cm [27]. On the other hand,\nmuch larger uteruses can also be delivered safely using a vagi-\nnal approach [28].\n\" If a patient has already had a Cesarean section or undergone\nother pelvic surgery, vaginal hysterectomy can be much more\ndifficult and the risk of injuring the bladder is increased. In this\ncase, the situation must be taken into consideration when indi-\ncating vaginal hysterectomy.\n\" In the case of suspected or confirmed uterine or ovarian malig-\nnancy, a purely vaginal procedure should not be the primary\nchoice. Selected patients with microinvasive cervical cancer or\nendometrial cancer are exceptions [29].\n7.2 Laparoscopically assisted vaginal hysterectomy\n(LAVH)\nLaparoscopically assisted vaginal hysterectomy (LAVH) combines\nlaparoscopic and vaginal surgical techniques. The use of laparos-\ncopy intends to avoid abdominal hysterectomy and enable vagi-\nnal hysterectomy. The laparoscopic part of the procedure in-\ncludes all of the steps that cannot be performed vaginally or that\ncan only be performed with a great deal of difficulty or increased\nrisk (adhesiolysis, excision of endometriotic nodules, adenec-\ntomy, detachment of the adnexa from the uterus). During LAVH,\ndissection in the area of the broad ligament of the uterus and the\nparametria ends above the uterine artery, which is detached\nfrom the vaginal side.\nThe uterus is extracted through the vagina and if needed, hemi-\notomy or morcellation is carried out.\nNo specific contraindications applying only to LAVH are known. If\nlaparoscopy is contraindicated in general, a purely vaginal or ab-\ndominal approach must be considered.\n7.3 Total laparoscopic hysterectomy (TLH)\nWith total laparoscopic hysterectomy (TLH), all steps of the pro-\ncedure are performed laparoscopically. In contrast to LAVH, the\ndissection of the uterine artery is performed laparoscopically, as\nis the paracervical dissection up to the vagina, the detachment of\nthe uterus from the vagina and the closure of the vagina by\nmeans of laparoscopic suturing. There is no switch from an ab-\ndominal to a vaginal approach. Due to the dissection, in particular\nin the area of the cervix, TLH must be learned as a separate surgi-\ncal procedure, even by surgeons with laparoscopic experience\n[30]. For this reason, systematic reviews [31] report about ele-\nvated rates of complications, especially in the area of the urogen-\nital tract, as well as increased risk of bleeding and relatively long\noperation times and recommend that this surgical procedure\nshould be considered as a secondary choice. However, at centers\nwith extensive TLH experience these problems have largely been\nresolved [30, 32]. Therefore, if there is sufficient experience with\nthe technique, its complication rate is similar to that of other lap-\n356\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGebFra Science\n\n\naroscopic surgical procedures. It appears that the operating time\nis longer than the operating time for vaginal hysterectomy and\nLAVH [31]. This is confirmed by the metaanalysis conducted by\nGendy et al. [33]. However, the metaanalysis also confirmed that\nwith the inclusion of 5 randomized controlled trials (RCTs) there\nwere no differences with respect to complication rates (LoE 2a,\nlevel decreased due to high heterogeneity of the study results\nand signs of publication bias).\nSeveral publications report postoperative dehiscences of the\nvaginal cuff in contrast to other modes of hysterectomy [34 – 36].\nThis is attributed to the high frequency surgical detachment of\nthe uterus from the vagina, whereby the endoscopic suturing\ntechnique is also discussed. A randomized study of vaginal stump\nsuturing techniques comparing vaginal and laparoscopic ap-\nproaches by an experienced surgeon did not yield any differences\n[37].\n7.4 Laparoscopic supracervical hysterectomy (LASH)\nLASH constitutes an alternative to abdominal, total vaginal and\ntotal laparoscopic hysterectomy. In 2010, supracervical hysterec-\ntomy was performed in 13.5 % of cases in Germany, most of them\nusing a laparoscopic approach [1]. In the United States, 2 % of all\nhysterectomies are performed supracervically, while in Scandi-\nnavia, around 36 % of all hysterectomies are performed as supra-\ncervical hysterectomies [38].\nWith LASH, the first steps are performed similar to the procedure\nfor LAVH and TLH and involve exposure of the site and dissection\nof possible associated pathologies (adhesions, endometriosis, ad-\nnexal abnormalities). Laparoscopic dissection ends at the level of\nthe uterovesical fold. The uterus is detached supracervically and\nafter intraabdominal morcellation is removed via the trocar.\nLASH is a procedure with a low complication rate [39 – 41]. De-\ntaching the uterine body from the cervix at the level of the isth-\nmus means that surgery in the area of the parametria and dissec-\ntion of the bladder is required to only a limited extent, if at all.\nThe complications reported for TLH, such as urinary tract lesions\nor dissection-related bleeding, are therefore rare for LASH.\n7.5 Abdominal hysterectomy\nIn addition to the general indication for a hysterectomy, the use\nof the abdominal approach involves the following special aspects:\n\" In addition to oncological indications, the size of the uterus and\nassociated disorders such as endometriosis or extensive adhe-\nsions resulting from previous surgery are indications for ab-\ndominal hysterectomy.\n\" An abdominal approach is also indicated depending on the in-\ndividual situation in patients with a long, narrow vagina, for\nnulliparous women and patients with comorbidities and in pa-\ntients for whom a vaginal or laparoscopic approach does not\nappear to be possible or would be associated with an increased\ncomplication risk. In case of doubt, when deciding whether ab-\ndominal hysterectomy is indicated, it may be helpful to per-\nform the pelvic examination under anesthesia by pulling on\nthe portio using bullet forceps.\n7.6 Robot-assisted hysterectomy\nRobot-assisted surgical procedures are used to a limited extent\nfor treating gynecological and obstetrics patients. They are often\nindicated in patients with cancer. Robot-assisted hysterectomy\ncan be implemented and can be performed quickly by a surgeon\nwith laparoscopic experience [42, 43]. Since the expenses and the\noperating time are far greater than those for conventional lapa-\nroscopy, in view of the limited resources, the use of robot-assis-\nted hysterectomy must be decided on a case-by-case basis [44 –\n47]. Systematic overview articles on robot-assisted hysterectomy\n(Tapper et al. 2014 [48], Liu et al. 2012 [49], Liu et al. 2014 [50])\nidentified the same 2 RCTs (Paraiso et al. 2013 [51], Sarlos et al.\n2010 [46] [LoE 1b]). The interpretation of both RCTs showed dif-\nferences in operating times. No differences were observed with\nregard to complications (blood loss, “minor” or “major” compli-\ncations or postoperative use of pain medication).\nWith regard to quality of life, Sarlos et al. – without blinding – ob-\nserved improvements in some aspects of quality of life after 3\nweeks and after 6 to 8 weeks, while Paraiso et al. did not observe\nany differences after 6 months. In both studies, the operating\ntime for robot-assisted hysterectomy was significantly longer\nthan for laparoscopic surgery, with Paraiso observing an average\nlonger time of 70 minutes and Sarlos reporting 20 minutes lon-\nger. The length of hospital stay did not differ.\nA systematic review of robot-assisted hysterectomy with a single\nsite port [52] found only retrospective series or case studies with\na median operating time of 109 minutes. No information on\ntransfusions was reported (LoE 3). No information on complica-\ntions or follow-up was reported. The procedure must still be con-\nsidered to be experimental.\n357\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGuideline\n\n\n8 Intraoperative and postoperative complications\n(l\" Table 4)\n9 Documentation\nEvery patient chart created for a patient undergoing a hysterec-\ntomy must include the indication, the symptoms and the findings\nof the patient. These comprise the general and specific history,\nespecially previous illnesses and operations, as well as the gener-\nal and gynecological examination results including imaging re-\nsults.\nChecklists have proven helpful for perioperative documentation.\nThe surgical report lists the date, diagnosis and summary of the\ntreatment plan, along with the names of the physicians involved.\nThe surgical report serves as a description of the surgical proce-\ndure and the findings observed during surgery. In the case of an\nuncomplicated hysterectomy, this description may be brief. A\nsurgical report becomes particularly important, however, if com-\nplications occur. It is recommended to clearly describe in the pri-\nmary report any special anatomic circumstances and other con-\nditions giving rise to complications. At critical points, such as in\nthe case of parametric bleeding, the surgeon should state that\nhe or she checked the ureter by means of inspection, palpation\nor exposure and acted properly and carefully.\nThe postoperative course must also be documented. The scope\nand results of a physical examination should be listed in the form\nof notes accompanied by the time of day. The same procedure\nshould be used for findings from other hospitals and institutes.\nThe discharge summary is also very important.\n10 Comparison of methods\nIn recent years, numerous publications and two systematic re-\nviews have compared methods. The recommendation of the Na-\ntional Institute for Health and Care Excellence (NICE) [54] was\nfirst drawn up in 2002 and was adapted in 2004 and 2006. Inde-\npendent of this recommendation, a Cochrane Review was con-\nducted and published in 2009 [31], LoE 1a. For the most part,\nthe reviews examine the same studies. Nieboer et al. recently\nevaluated 34 studies with a total of 4495 women. The NICE pub-\nlication also evaluated a control study with 37 049 women and a\ncontrol study with 10 100 women.\nThe advantages of vaginal hysterectomy compared to abdominal\nhysterectomy involved the significantly shorter recovery time\n(mean difference [MD] 9.5 days), fewer febrile episodes and un-\nspecific infections (OR 0.42) and shorter hospital stays (MD 1.1\nTable 4 Incidence of intraoperative and postoperative complications.\nFINHYST 2011 (complication) n = 5 279 (%) AQUA 2012 (complication) n = 103 232 (%)\nIntraoperative blood loss ≥ 1 000 ml AH\nLH\nVH\n5.7\n3.0\n1.6\nIntraoperative blood loss ≥ 1 000 ml No comparative data\nBladder injury AH\nLH\nVH\n0.9\n1.0\n0.6\nBladder injury 0.59\nUreter injury AH\nLH\nVH\n0.3\n0.3\n0.04\nUreter injury 0.09\nBowel injury AH\nLH\nVH\n0.2\n0.4\n0.1\nBowel injury 0.23\nPostoperative bleeding or hematoma AH\nLH\nVH\n2.6\n2.7\n2.8\nPostoperative bleeding or hematoma 0.94\nIleus AH\nLH\nVH\n1.0\n0.3\n0.1\nIleus 0.09\nUrinary retention AH\nLH\nVH\n0.5\n0.5\n1.6\nUrinary retention No comparable data\nUrinary tract infection AH\nLH\nVH\n2.2\n0.7\n1.5\nUrinary tract infection 1.0\nWound infection AH\nLH\nVH\n2.4\n1.5\n0.9\nWound infection No comparable data\nFebrile events AH\nLH\nVH\n2.5\n1.4\n0.9\nFebrile events 0.28\nPelvic infection, hematoma or abscess 10\n54\n51\n1.00\n5.08\n5.40\nPelvic infection, hematoma or ab-\nscess\nNo comparable data\nFINHYST study: n = 5 279 with 1 255 abdominal, 1 679 laparoscopic and 2 345 vaginal hysterectomies in Finland in 2006 [53]; AQUA 2012: n = 103 232 independent of approach and\ndistinction between endoscopically performed hysterectomies, only exact mention of 16 196 abdominal hysterectomies and 57 398 vaginal hysterecto mies.\nAbbreviations: AH = abdominal hysterectomy, LH = laparoscopic hysterectomy, VH = vaginal hysterectomy\n358\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGebFra Science\n\n\ndays). When comparing vaginal hysterectomy with laparoscopic\nhysterectomy (LH), no significant differences were found in this\nrespect. However the operating time was longer for LH (MD 39.3\nminutes) and severe bleeding occurred more frequently (OR\n2.76). The Cochrane Review concluded that owing to the same\nor significantly more favorable results across the board, vaginal\nhysterectomy should be preferred over abdominal hysterectomy\nwhenever possible. If a vaginal hysterectomy is not possible, lap-\naroscopic procedures can be used to avoid the disadvantages of a\nlaparotomy due to the more favorable adverse effect profile [27].\nThe American College of Obstetricians and Gynecologists came\nup with the same recommendations [55].\nDiverse comparative analyses have come up with identical re-\nsults for the procedure with the lowest costs, which is vaginal\nhysterectomy.\nIn addition to the systematic review by Nieboer et al., after updat-\ning the search to include publications up to June 2014, other sys-\ntematic overview articles were included on the following issues\nrelated to the comparison of methods ( l\n\" Tables 5 und 6):\nEvidence-based recommendation 10.E22\nIf possible, vaginal hysterectomy must be favored over abdominal\nhysterectomy. (LoEOxford 2009 1a, GR A)\nConsensus strength (+++)\nLiterature: [42, 56, 57]\nEvidence-based recommendation 10.E23\nIf vaginal hysterectomy is not possible, the possibility of laparo-\nscopic hysterectomy should be reviewed. (LoE\nOxford 2009 1a, GR B)\nConsensus strength (+++)\nLiterature: [42, 58]\nEvidence-based recommendation 10.E24\nLASH may be performed as an alternative to abdominal hysterec-\ntomy and vaginal hysterectomy. (LoE\nOxford 2009 1a, GR 0)\nConsensus strength (+++)\nLiterature: [59]\nConsensus-based statement 10.S8\nHowever, current data do not permit the different laparoscopic\ntechniques to be exactly differentiated. (expert consensus)\nConsensus strength (+++)\nConsensus-based recommendation 10.E25\nAbdominal hysterectomy should only be performed if it is specif-\nically indicated. (expert consensus)\nConsensus strength (+++)\nEvidence-based statement 10.S9\nIn the available randomized studies, no confirmed patient-\nrelated benefits were found for the use of robot-assisted technol-\nogy. (LoE\nOxford 2009 1b)\nLiterature: [45– 47]\n11 Special situation – What do I do if …?\n11.1 Hysterectomy for adenomyosis/endometriosis\nConsensus-based recommendation 11.E26\nIf the patient has the relevant symptoms, there is no desire for\nfertility and there are clinical signs of adenomyosis, a hysterec-\ntomy should be performed. (expert consensus)\nConsensus strength (+++)\nConsensus-based statement 11.S10\nFor deep infiltrating endometriosis, a hysterectomy may be indi-\ncated in the overall concept of complete resection. (expert con-\nsensus)\nConsensus strength (+++)\nTable 5 Comparison of hysterectomy methods\nVaginal hysterectomy vs. abdominal hysterectomy\nQuicker return to normal activity Average difference 9.5 days\nFewer febrile events, fewer febrile\nepisodes and specific infections\nOR 0.42; CI 0.21–0.83\nShorter hospital stay Average difference 1.1 days\nLH vs. abdominal hysterectomy\nReturn to normal activity Average difference 13.6 days\nLower blood loss Average 45 cm\n3\nLower drop in HB Average difference 0.55 g/dl\nShorter hospital stay Average difference 2.0 days\nLess wound and abdominal infiltrates OR 0.31; CI 0.12 –0.77\nMore bladder and ureter injuries OR 2.41; CI 1.21 –4.82\nLonger operating time Average 2.3 min\nLAVH vs. TLH\nLower rate of infection OR 3.77; CI 1.05 –13.51\nShorting operating time Average 25.3 min\nVH vs. LH\nShorter operating time Average 39.3 min\nLess intraoperative bleeding OR 2.76; CI 1.02 –7.42\nTable 6 Comparison of different hysterectomy modalities.\nOperating time Blood loss Complications Admission period Return to work Costs\nVaginal hysterectomy +++ +++ +++ +++ +++ +++\nLAVH ++ +++ +++ +++ +++ ++\nTLH ++ ++(+) ++(+) +++ +++ ++\nLASH ++ +++ +++ +++ +++ ++\nAbdominal HE ++ ++ ++ + + ++\nNumber of “+” means increasing advantage of the method.\n359\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGuideline\n\n\n11.2 Hysterectomy and incontinence\nIf a patient for whom a hysterectomy is indicated is to undergo\nsurgery for stress incontinence at the same time, the hysterec-\ntomy may be performed using the most straightforward proce-\ndure. The stress incontinence surgery does not impact the meth-\nod used for hysterectomy.\n11.3 Obstetric hysterectomy for postpartum\nhemorrhage\nConsensus-based recommendation 11.E27\nFor postpartum, life-threatening uterine bleeding and the failure\nof alternative treatment options, a hysterectomy is indicated as a\nlast resort and in the event of a life-threatening situation. (expert\nconsensus)\nConsensus strength (+++)\n12 Quality of life\nEvidence-based recommendation 12.E28\nPatients should be informed that after they have undergone an\nindicated hysterectomy, they can generally expect to experience\nimprovement in quality of life and sexual functioning compared\nto their preoperative situation. (LoE\nOxford 2009 1a, GR B)\nLiterature: [60– 63]\nEvidence-based statement 12.S11\nA prophylactic bilateral adnexectomy may be associated with un-\ndesired long-term adverse effects and requires separate informa-\ntion and consent. (LoE\nOxford 2009 1a)\nConsensus strength (++)\nLiterature: [64, 65]\n13 Algorithm: Alternatives to hysterectomy\n(l\" Figs. 1 to 3)\nUterine fibroids\nDiscontinue treatment\nSymptoms?\nFertility no longer desired?\nPatient would like…\nHysterectomyUterine artery embolization (UAE)\nSymptoms improved?\nObserve\nNo\nNoNo\nYes Yes\nNo\nYes\nYes\nSymptoms improved and/or\npregnancy planned?\nMyomectomy\nhysteroscopic and/or\nlaparoscopic\nopen surgery\nFig. 1 Pathway: Uterine fibroids.\n360\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGebFra Science\n\n\nMenstrual disorder\nDiscontinue treatment\nSymptoms improved?\nSymptoms improved?\nSymptoms improved?\nFertility no longer desired?\nOral contraceptives\npossibly long-term use\nEndometrial ablation\nHysterectomy\nPlan a pregnancy\nYes\nYes\nYes\nYes\nNo\nNo\nNo\nNo\nProgestogens\nsystemic\nlocal\nFig. 2 Pathway: Menstrual disorder.\nEndometriosis/adenomyosis\nDiscontinue treatment\nSymptoms improved?\nSymptoms improved?\nSymptoms improved?\nPatiend would like…\nPlan a pregnancy HysterectomyShort-term use of GnRH analogues\n(monitor for adverse effects!)\nFertility no longer desired?\nOral contraceptives\nPreferably long-term use\nYes\nYes\nYes\nNo\nNo\nNo\nYesNo\nProgestogens\nsystemic\nlocal\nFig. 3 Pathway: Endometriosis/adenomyosis.\n361\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGuideline\n\n\nAffiliations\n1 Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin\nder Universitätsklinik des Saarlandes\n2 Frauenklinik des Universitätsklinikum Tübingen\n3 Evangelisches Krankenhaus Köln-Weyertal\n4 Klinik für Neurochirurgie der Universitätsklinik des Saarlandes\n5 Klinik für Gynäkologie und Geburtshilfe Universitätsklinikum\nSchleswig-Holstein\n6 Klinik für Gynäkologie und Geburtshilfe Krankenhaus Agatharied GmbH\n7 Klinik für Frauenheilkunde und Geburtshilfe St. Elisabeth Krankenhaus\nDamme\n8 Klinik für MIC Minimal Invasive Chirurgie am Ev. Krankenhaus Hubertus\nin Berlin\n9 Frauenklinik des Universitätsklinikum Tübingen\n10 Klinik für Gynäkologie und Geburtshilfe St. Josefs-Hospital Wiesbaden\n11 Privates Brustzentrum Rheinfelden\n12 Universitätsklinikum Jena Klinik für Frauenheilkunde und Geburtshilfe\n13 Universitätsklinikum Mannheim Klink für Frauenheilkunde und Geburtshilfe\n14 Klinik für Gynäkologie und Geburtshilfe Christian-Albrechts-Universität\nzu Kiel\n15 Dysplasiezentrum Reutlingen\n16 Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe Klinikum\nder Universität München\n17 Campus Virchow-Klinikum Charité Klinik für Gynäkologie\n18 Institut für Pathologie Universitätsklinikum Leipzig\n19 Institut für Pathologie Mannheim\n20 Universitätsklinikum Erlangen Frauenklinik\n21 Frauenklinik Aschaffenburg\n22 Frauenärzte-West Saarbrücken\n23 Krankenhaus der Barmherzigen Schwestern Linz\n24 Inselspital Bern\n25 Kantonsspital Frauenfeld\n26 Universitäts-Frauenklinik Graz\nReferences\n1 AQUA – Institut für angewandte Qualitätsförderung und Forschung im\nGesundheitswesen GmbH Mh-, 37073 Göttingen. AQUA. Bundesauswer-\ntung zum Verfahrensjahr 2012. 15/1 Gynäkologische Operationen.\n2013. Online: https://wwwsqgde/downloads/Bundesauswertungen/\n2012/bu_Gesamt_15N1-GYN-OP_2012pdf; last access: 05.01.2015\n2 Lethaby A, Vollenhoven B, Sowter M. Pre-operative GnRH analogue\ntherapy before hysterectomy or myomectomy for uterine fibroids. Co-\nchrane Database Syst Rev 2001; 2: CD000547\n3 Zhang Y, Sun L, Guo Y et al. The impact of preoperative gonadotropin-\nreleasing hormone agonist treatment on women with uterine fibroids:\na meta-analysis. Obstet Gynecol Surv 2014; 69: 100 – 108\n4 Donnez J, Tatarchuk TF, Bouchard P et al. Ulipristal acetate versus\nplacebo for fibroid treatment before surgery. N Engl J Med 2012; 366:\n409– 420\n5 Donnez J, Tomaszewski J, Vazquez F et al. Ulipristal acetate versus leu-\nprolide acetate for uterine fibroids. N Engl J Med 2012; 366: 421 – 432\n6 Fergusson RJ, Lethaby A, Shepperd S et al. Endometrial resection and\nablation versus hysterectomy for heavy menstrual bleeding. Cochrane\nDatabase Syst Rev 2013; 11: CD000329\n7 Ozdegirmenci O, Kayikcioglu F, Akgul MA et al. Comparison of levonor-\ngestrel intrauterine system versus hysterectomy on efficacy and qual-\nity of life in patients with adenomyosis. Fertil Steril 2011; 95: 497 – 502\n8 Obstetrics GotGSoGa. Diagnosis and treatment of endometriosis (S2k).\n2013; AWMF Registry No. 015/045. Online: http://www.awmf.org/\nleitlinien/detail/ll/015-045.html; last access: 04.04.2016\n9 Obstetrics GotGSoGa. HPV-Infektion/präinvasive Läsionen des weibli-\nchen Genitale: Prävention, Diagnostik und Therapie (S2). In Überarbei-\ntung. 2008. Online: http://www.awmf.org/leitlinien/detail/ll/015-027.\nhtml; last access: 04.04.2016\n10 Obstetrics GotGSoGa. Descensus genitalis der Frau (S1). 2010; AWMF\nRegistry No. 015/006 (Band I). Online: http://www.awmf.org/\nleitlinien/detail/ll/015-06.html; last access: 04.04.2016\n11 Darai E, Jeffry L, Deval B et al. Results of tension-free vaginal tape in pa-\ntients with or without vaginal hysterectomy. Eur J Obstet Gynecol Re-\nprod Biol 2002; 103: 163 – 167\n12 Obstetrics GotGSoGa. Leitlinie: Chronischer Unterbauchschmerz der\nFrau (S2k). AWMF Registry No 016/001. In Überarbeitung. 2009. On-\nline: http://www.awmf.org/leitlinien/detail/ll/016-001.html; last ac-\ncess: 04.04.2016\n13 Brandsborg B, Dueholm M, Nikolajsen L et al. A prospective study of risk\nfactors for pain persisting 4 months after hysterectomy. Clin J Pain\n2009; 25: 263 – 268\n14 Brandsborg B, Nikolajsen L, Kehlet H et al. Chronic pain after hysterec-\ntomy. Acta Anaesthesiol Scand 2008; 52: 327 – 331\n15 American College of Obstetricians and Gynecologists. ACOG practice bul-\nletin. Alternatives to hysterectomy in the management of leiomyomas.\nObstet Gynecol 2008; 112 (2 Pt 1): 387 – 400\n16 Heliovaara-Peippo S, Hurskainen R, Teperi J et al. Quality of life and\ncosts of levonorgestrel-releasing intrauterine system or hysterectomy\nin the treatment of menorrhagia: a 10-year randomized controlled tri-\nal. Am J Obstet Gynecol 2013; 209: 535.e1 – 535.e14\n17 Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing in-\ntrauterine systems for heavy menstrual bleeding. Cochrane Database\nSyst Rev 2005; 4: CD002126\n18 Lethaby A, Hickey M, Garry R et al. Endometrial resection/ablation\ntechniques for heavy menstrual bleeding. Cochrane Database Syst Rev\n2009; 4: CD001501\n19 Teichmann A. Der medizinische Sachverständige. In: Wenzel F, Hrsg.\nDer Arzthaftungsprozess. München: Verlag C. H. Beck oHG; 2011\n20 de Vries EN, Prins HA, Crolla RM et al. Effect of a comprehensive surgical\nsafety system on patient outcomes. N Engl J Med 2010; 363: 1928\n–\n1937\n21 Obstetrics GotGSoGa. Operationsbedingte Verletzungen des Ureters in\nder Gynäkologie und Geburtshilfe (S1). 2010; AWMF Registry\nNo. 015/061 (Band IV). Online: http://www.awmf.org/leitlinien/detail/\nll/015-061.html; last access: 04.04.2016\n22 Haynes AB, Weiser TG, Berry WR et al. A surgical safety checklist to re-\nduce morbidity and mortality in a global population. N Engl J Med\n2009; 360: 491 – 499\n23 Parzeller M, Wenk M, Zedler B et al.. Aufklärung und Einwilligung bei\närztlichen Eingriffen. Dtsch Arztebl 2007; 104: A576 – A586\n24 WHO. Surgical safety checklist and implementation manual. 2010.\nOnline: http://www.who.int/patientsafety/safesurgery/ss_checklist/\nen/; last access: 04.04.2016\n25 Fanning J, Valea FA. Perioperative bowel management for gynecologic\nsurgery. Am J Obstet Gynecol 2011; 205: 309 – 314\n26 OʼNeal MG, Beste T, Shackelford DP. Utility of preemptive local analgesia\nin vaginal hysterectomy. Am J Obstet Gynecol 2003; 189: 1539 – 1541;\ndiscussion 1541– 1542\n27 Kovac SR. Hysterectomy outcomes in patients with similar indications.\nObstet Gynecol 2000; 95 (6 Pt 1): 787 – 793\n28 Deval B, Rafii A, Soriano D et al. Morbidity of vaginal hysterectomy for\nbenign tumors as a function of uterine weight. J Reprod Med 2003; 48:\n435– 440\n29 Obstetrics GotGSoGa. Diagnosis and treatment of cervical carcimoma.\n2010; AWMF Registry No. 032/033 (S3). Online: http://www.awmf.\norg/leitlinien/detail/ll/032-033OL.html; last access: 04.04.2016\n30 Donnez O, Donnez J. A series of 400 laparoscopic hysterectomies for be-\nnign disease: a single centre, single surgeon prospective study of com-\nplications confirming previous retrospective study. BJOG 2010; 117:\n752– 755\n31 Nieboer TE, Johnson N, Lethaby A et al. Surgical approach to hysterec-\ntomy for benign gynaecological disease. Cochrane Database Syst Rev\n2009; 3: CD003677\n32 Holthaus B. Komplikationen bei der TLH – ein 5-Jahres-Rückblick bei\n800 Hysterektomien. ETC Saarbrücken, 2011; Vortrag Hysterektomie\nWorkshop\n33 Gendy R, Walsh CA, Walsh SR et al. Vaginal hysterectomy versus total\nlaparoscopic hysterectomy for benign disease: a metaanalysis of ran-\ndomized controlled trials. Am J Obstet Gynecol 2011; 204: 388.e1 –\n388.e8\n34 Agdi M, Al-Ghafri W, Antolin R et al. Vaginal vault dehiscence after hys-\nterectomy. J Minim Invasive Gynecol 2009; 16: 313 – 317\n35 Hur HC, Donnellan N, Mansuria S et al. Vaginal cuff dehiscence after dif-\nferent modes of hysterectomy. Obstet Gynecol 2011; 118: 794 – 801\n36 Iftner T, Eberle S, Iftner A et al. Prevalence of low-risk and high-risk\ntypes of human papillomavirus and other risk factors for HPV infection\nin Germany within different age groups in women up to 30 years of\nage: an epidemiological observational study. J Med Virol 2010; 82:\n1928– 1939\n37 Jeung IC, Baek JM, Park EK et al. A prospective comparison of vaginal\nstump suturing techniques during total laparoscopic hysterectomy.\nArch Gynecol Obstet 2010; 282: 631 – 638\n362\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGebFra Science\n\n\n38 Kives S, Lefebvre G, Wolfman W et al. Supracervical hysterectomy.\nJ Obstet Gynaecol Can 2010; 32: 62 – 68\n39 Bojahr B, Raatz D, Schonleber G et al. Perioperative complication rate in\n1706 patients after a standardized laparoscopic supracervical hyster-\nectomy technique. J Minim Invasive Gynecol 2006; 13: 183 – 189\n40 Learman LA, Summitt RL jr., Varner RE et al. A randomized comparison\nof total or supracervical hysterectomy: surgical complications and\nclinical outcomes. Obstet Gynecol 2003; 102: 453 – 462\n41 Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterec-\ntomy for benign gynaecological conditions. Cochrane Database Syst\nRev 2012; 4: CD004993\n42 Kho RM, Hilger WS, Hentz JG et al. Robotic hysterectomy: technique and\ninitial outcomes. Am J Obstet Gynecol 2007; 197: 113.e1 – 113.e4\n43 Payne TN, Dauterive FR, Pitter MC et al. Robotically assisted hysterec-\ntomy in patients with large uteri: outcomes in five community prac-\ntices. Obstet Gynecol 2010; 115: 535 – 542\n44 Landeen LB, Bell MC, Hubert HB et al. Clinical and cost comparisons for\nhysterectomy via abdominal, standard laparoscopic, vaginal and ro-\nbot-assisted approaches. S D Med 2011; 64: 197 – 199, 201, 203 passim\n45 Pasic RP, Rizzo JA, Fang H et al. Comparing robot-assisted with conven-\ntional laparoscopic hysterectomy: impact on cost and clinical out-\ncomes. J Minim Invasive Gynecol 2010; 17: 730 – 738\n46 Sarlos D, Kots L, Stevanovic N et al. Robotic hysterectomy versus con-\nventional laparoscopic hysterectomy: outcome and cost analyses of a\nmatched case-control study. Eur J Obstet Gynecol Reprod Biol 2010;\n150: 92– 96\n47 Scandola M, Grespan L, Vicentini M et al. Robot-assisted laparoscopic\nhysterectomy vs. traditional laparoscopic hysterectomy: five metaa-\nnalyses. J Minim Invasive Gynecol 2011; 18: 705 – 715\n48 Tapper AM, Hannola M, Zeitlin R et al. A systematic review and cost\nanalysis of robot-assisted hysterectomy in malignant and benign con-\nditions. Eur J Obstet Gynecol Reprod Biol 2014; 177: 1 – 10\n49 Liu H, Lu D, Wang L et al. Robotic surgery for benign gynaecological dis-\nease. Cochrane Database Syst Rev 2012; 2: CD008978\n50 Liu H, Lawrie TA, Lu D et al. Robot-assisted surgery in gynaecology. Co-\nchrane Database Syst Rev 2014; 12: CD011422\n51 Paraiso MF, Ridgeway B, Park AJ et al. A randomized trial comparing\nconventional and robotically assisted total laparoscopic hysterectomy.\nAm J Obstet Gynecol 2013; 208: 368.e1 – 368.e7\n52 Iavazzo C, Gkegkes ID. Single-site port robotic-assisted hysterectomy: a\nsystematic review. Arch Gynecol Obstet 2014; 289: 725 – 731\n53 Brummer TH, Jalkanen J, Fraser J et al. FINHYST, a prospective study of\n5279 hysterectomies: complications and their risk factors. Hum Re-\nprod 2011; 26: 1741 – 1751\n54 NICE NIfHaCE. Interventional procedure overview of laparoscopic\ntechniques for hysterectomy. Online: www.nice.org.uk/nicemedia/\nlive/11045/38409/38409.pdf; last access: 11.01.2016\n55 ACOG Committee Opinion No. 444: choosing the route of hysterec-\ntomy for benign disease. Obstet Gynecol 2009; 114: 1156 – 1158\n56 Garry R, Fountain J, Brown J et al. EVALUATE hysterectomy trial: a mul-\nticentre randomised trial comparing abdominal, vaginal and laparo-\nscopic methods of hysterectomy. Health Technol Assess 2004; 8: 1 –\n154\n57 Garry R, Fountain J, Mason S et al. The eVALuate study: two parallel ran-\ndomised trials, one comparing laparoscopic with abdominal hysterec-\ntomy, the other comparing laparoscopic with vaginal hysterectomy.\nBMJ 2004; 328: 129\n58 Brandner P, Neis KJ. Combined laparoscopic and vaginal surgery: saving\nof time by means of a new type of OR draping cloth. Gynaecological En-\ndoscopy 1997; 6: 291 – 294\n59 Janssen PF, Brolmann HA, Huirne JA. Recommendations to prevent uri-\nnary tract injuries during laparoscopic hysterectomy: a systematic Del-\nphi procedure among experts. J Minim Invasive Gynecol 2011; 18:\n314– 321\n60 Matteson KA, Abed H, Wheeler TL 2nd et al. A systematic review com-\nparing hysterectomy with less-invasive treatments for abnormal uter-\nine bleeding. J Minim Invasive Gynecol 2012; 19: 13 – 28\n61 Franchini M, Franchi M, Bergamini V et al. The use of recombinant acti-\nvated FVII in postpartum hemorrhage. Clin Obstet Gynecol 2010; 53:\n219– 227\n62 Rannestad T, Eikeland OJ, Helland H et al. The quality of life in women\nsuffering from gynecological disorders is improved by means of hys-\nterectomy. Absolute and relative differences between pre- and postop-\nerative measures. Acta Obstet Gynecol Scand 2001; 80: 46 – 51\n63 Rhodes JC, Kjerulff KH, Langenberg PW et al. Hysterectomy and sexual\nfunctioning. JAMA 1999; 282: 1934 – 1941\n64 Novetsky AP, Boyd LR, Curtin JP. Trends in bilateral oophorectomy at the\ntime of hysterectomy for benign disease. Obstet Gynecol 2011; 118:\n1280– 1286\n65 Orozco LJ, Salazar A, Clarke J et al. Hysterectomy versus hysterectomy\nplus oophorectomy for premenopausal women. Cochrane Database\nSyst Rev 2008; 3: CD005638\n363\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGuideline\n\n\nGuideline Program\nEditors\nLeading Professional Medical Associations\nGerman Society of Gynecology and Obstetrics\n(Deutsche Gesellschaft für Gynäkologie\nund Geburtshilfe e. V. [DGGG])\nHead Office of DGGG and Professional Societies\nHausvogteiplatz 12\nDE-10117 Berlin\ninfo@dggg.de\nhttp://www.dggg.de/\nPresident of DGGG\nProf. Dr. med. Diethelm Wallwiener\nUniversitätsfrauenklinik Tübingen\nCalwerstraße 7\nDE-72076 Tübingen\nDGGG Guidelines Representative\nProf. Dr. med. Matthias W. Beckmann\nUniversitätsklinikum Erlangen\nFrauenklinik\nUniversitätsstraße 21– 23\nDE-91054 Erlangen\nGuidelines Coordination\nDr. med. Paul Gaß, Tobias Brodkorb, Marion Gebhardt\nUniversitätsklinikum Erlangen\nFrauenklinik\nUniversitätsstraße 21– 23\nDE-91054 Erlangen\nfk-dggg-leitlinien@uk-erlangen.de\nhttp://www.dggg.de/leitlinienstellungnahmen\nAustrian Society of Gynecology and Obstetrics\n(Österreichische Gesellschaft für Gynäkologie\nund Geburtshilfe [OEGGG])\nInnrain 66A\nAT-6020 Innsbruck\nstephanie.leutgeb@oeggg.at\nhttp://www.oeggg.at\nPresident of OEGGG\nProf. Dr. med. Uwe Lang\nUniversitätsklinik für Frauenheilkunde\nund Geburtshilfe Graz\nAuenbruggerplatz 14\nAT-8036 Graz\nOEGGG Guidelines Representative\nProf. Dr. med. Karl Tamussino\nUniversitätsklinik für Frauenheilkunde\nund Geburtshilfe Graz\nAuenbruggerplatz 14\nAT-8036 Graz\nSwiss Society of Gynecology and Obstetrics\n(Schweizerische Gesellschaft für Gynäkologie\nund Geburtshilfe [SGGG])\nGynécologie Suisse SGGG\nAltenbergstraße 29\nPostfach 6\nCH-3000 Bern 8\nsekretariat@sggg.ch\nhttp://www.sggg.ch/\nPresident of SGGG\nDr. med. David Ehm\nFMH für Geburtshilfe und Gynäkologie\nNägeligasse 13\nCH-3011 Bern\nSGGG Guidelines Representative\nProf. Dr. med. Daniel Surbek\nUniversitätsklinik für Frauenheilkunde\nGeburtshilfe und feto-maternale Medizin\nInselspital Bern\nEffingerstraße 102\nCH-3010 Bern\ngynécologie \nsuisse\n364\nNeis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364\nGebFra Science","source_license":"public-domain-us","license_restricted":false}