A Suggested Strategy to Reduce Stump Carcinoma After Performing “Obligatory” Subtotal Hysterectomy

Abstract

During years of work in gynecologic oncology unit, we have noticed a progressive increase in incidence of stump carcinoma referred to our unit. This was parallel to increased rate of performing subtotal hysterectomy (STH). The authors contacted some colleagues of different training levels and found that performing subtotal hysterectomy in many cases was attributed to ‘‘reasonable’’ or ‘‘obligatory’’ causes, and in other cases, it could be considered as malpractice. We wanted to address this issue in this report. It is well known that performing total rather than subtotal hysterectomy is the standard operation for treatment of benign lesions to avoid stump carcinoma [1]. Stump carcinoma occurs in 0.3–1.9% and may develop years after subtotal hysterectomy, especially in unscreened population [2]. Stump carcinoma has bad prognosis due to rapid spread to the adjacent urinary bladder and rectum in addition to difficult surgical treatment in the presence of adhesions and distorted anatomy [3]. In certain situations, subtotal hysterectomy may be ‘‘obligatory’’ where the removal of cervix uteri may expose the patient to injury of bladder, ureter, or other organs. Extensive pelvic adhesions occur frequently following endometriosis, infection, and repeated surgeries [4]. Subtotal hysterectomy sometimes were done to shorten operative time as in cases of severe intraoperative hemorrhage and bad general condition of the patient. Obstetric ‘‘peripartum’’ hysterectomy is usually performed as ‘‘supracervical’’ due to difficult demarcation of portio vaginalis of cervix and upper vagina [5]. Furthermore, the rate of peripartum hysterectomy increased in the last years following increased incidence of abnormally adherent placenta secondary to increased cesarean section rate [6]. We defined obligatory STH when the operator is obliged to perform STH due to previous causes, although he/she is well experienced to perform total hysterectomy.