TLH versus LSH: what does the evidence say?

Hysterectomy is the most common surgical procedure performed in gynaecology and, in over 95% of cases, does not necessarily require the removal of the uterine cervix to be completed successfully. In clinical practice, however, fewer than 10% of gynaecologists offer patients the possibility to express a personal preference concerning the choice between total laparoscopic hysterectomy (TLH) and laparoscopic subtotal hysterectomy (LSH).

Advocates of LSH suggest possible advantages including reduced recovery time, decreased risk of pelvic organ prolapse, and decreased risk of organ damage, in particular to the urinary tract. Opponents of LSH have suggested possible future risk of cervical malignancy and the possibility of ongoing cyclical bleeding. It is mandatory to counsel women to have regular pap smears after LSH.

We are presenting a short summary of current evidence.

In a study of 1,016 patients (Harmani et al 2009), most of the perioperative outcome measures did not differ statistically between the groups. However, the risk of serious complications was higher for TLH; specifically, urinary tract injury occurred more frequently in TLH. Conversion to laparotomy was also more common in TLH.

The largest single-centre study (Wallwiener et al 2013) from January 2003 to December 2010 involved 1,952 patients and observed: Overall intraoperative and long-term complication rates did not differ significantly, but the short-term LSH complication rate was significantly lower (0.6 vs 4.8%). Spotting (LSH, 0.2 %) and vaginal cuff dehiscence (TLH, 0.7%) were long-term, method-specific complications.

A French study (Gé P et al 2015) and an Italian study (Saccardi C et al 2015) seem to indicate an improvement on certain criteria in the evaluation of sexuality in the LSH group, in particular on the orgasm.

A Canadian experience of 390 cases (Van Evert et al 2010) suggested that long-term complications such as cervical stump reoperation were higher in LSH group.

A randomised control trial with 62 patients (Berner Et al 2015) evaluating patient satisfaction and quality of life showed no difference between the groups.

Currently, there is vigorous academic discourse regarding the use of power morcellation and how this can be used with continued safety and efficacy.

We are currently exploring the use of so-called “in bag-morcellation” to continue to offer LSH to our patients.

Bottom Line: At WA GynaeScope, we feel strongly about evidence-based care for our patients. We continue to offer both TLH and LSH options to our patients and are counselling them appropriately.