Indications for Hysterectomy
Hysterectomy is considered when:
- Conservative treatments (medical therapy, endometrial ablation, UAE/fibroid embolisation, myomectomy) have failed or are not appropriate
- The condition is significantly impairing quality of life
- Malignancy is confirmed or highly suspected
Uterine fibroids (leiomyomata): The most common indication. Fibroids causing heavy menstrual bleeding, pelvic pain, pressure symptoms (bladder/bowel), or reproductive failure - especially multiple, large, or intramural fibroids not suitable for myomectomy. Hysterectomy is the definitive treatment and eliminates fibroid recurrence risk.
Endometriosis: Severe endometriosis with pain unresponsive to hormonal treatment and repeated conservative surgery - combined hysterectomy with bilateral salpingo-oophorectomy (BSO) for women who have completed their family and have ovarian endometriosis.
Adenomyosis: Diffuse or focal (adenomyoma) uterine glandular invasion of myometrium - causing severe dysmenorrhoea and heavy bleeding; hysterectomy is the only cure when medical therapy fails.
Uterine prolapse: Significant prolapse (Grade III-IV) causing pelvic floor dysfunction - vaginal hysterectomy - pelvic floor repair.
Abnormal uterine bleeding: Heavy menstrual bleeding uncontrolled by medical treatment or endometrial ablation.
Gynaecological malignancy: Endometrial cancer (most common), cervical cancer (early stage radical hysterectomy), ovarian cancer debulking - discussed under the cancer surgery section.
Surgical Approaches - Laparoscopic, Robotic, Vaginal
Total Laparoscopic Hysterectomy (TLH): The most common approach for benign gynaecological conditions:
- 3-4 small (5-10 mm) port incisions; CO- pneumoperitoneum
- Uterine vessels ligated laparoscopically; uterus detached and removed vaginally (morcellation within bag if safe) or via colpotomy
- Hospital: 1-2 nights; return to light activity: 1-2 weeks vs. 4-6 weeks open
Robotic-Assisted Hysterectomy (da Vinci):
- Superior instrument dexterity and 3D visualisation via the da Vinci system
- Particularly valuable for: large uteri, significant pelvic adhesions, complex endometriosis, and morbidly obese patients where laparoscopic angles are difficult
- Outcomes equivalent to standard laparoscopy; valuable in complex cases
- Available at select BB Global Health partner hospitals
Laparoscopic-Assisted Vaginal Hysterectomy (LAVH): Combination approach - laparoscopic upper pedicle ligation; final dissection and uterus removal vaginally. Useful in selected cases.
Vaginal Hysterectomy: For uterovaginal prolapse - uterus removed entirely per vaginum; no abdominal incisions. Often combined with anterior and posterior colporrhaphy (pelvic floor repair) and vault suspension.
Open Abdominal Hysterectomy (TAH/Pfannenstiel):
- Reserved for: very large uteri (>20 weeks size), known/suspected malignancy with staging requirement, or conversion from laparoscopic approach
- Longer hospital stay (3-5 nights) and recovery (4-6 weeks)
Subtotal vs. total:
- Total hysterectomy: Uterus and cervix both removed - standard approach; eliminates need for future cervical smears
- Subtotal (cervix-sparing): Historically used; cervix preserved; requires ongoing cervical screening; rarely performed today
Recovery After Hysterectomy
Hospital stay:
- Laparoscopic/robotic hysterectomy: 1-2 nights
- Vaginal hysterectomy: 1-3 nights
- Open (abdominal) hysterectomy: 3-5 nights
Post-operative course:
- Day 0-1: Catheter removed next morning; walking same day; light diet
- Day 1-2: Discharge home or to hotel; oral analgesics
- Days 3-10 (hotel): Light activity; short walks; no driving; no heavy lifting
- Weeks 2-6: Gradual return to normal activities; pelvic rest (no intercourse) for 6 weeks
Return to activities:
- Light work/desk activities: 1-2 weeks (laparoscopic)
- Driving: 2-3 weeks
- Full activities: 4-6 weeks
- Open surgery: 6 weeks for most activities
Hormonal considerations after hysterectomy:
- If ovaries preserved (hysterectomy without oophorectomy): menstruation stops but menopause is not induced; ovaries continue hormonal function
- If bilateral oophorectomy (BSO) performed: surgical menopause induced - HRT is recommended unless contraindicated, particularly for women under 50
VTE prevention: Low molecular weight heparin post-op and compression stockings. Flight-safe walking encouraged; flight no earlier than 7-10 days post-laparoscopic; 14 days post-open surgery.
Cost comparison: Laparoscopic hysterectomy Turkey all-inclusive: -5,500-9,000; UK private: -12,000-20,000. Robotic hysterectomy Turkey: -7,000-12,000; UK private: -15,000-28,000.