Hysterectomy in Turkey

Hysterectomy, or surgical removal of the uterus, is the surgical removal of the uterus, the main organ of the female reproductive system, from the body in accordance with medical necessities. This major surgical intervention, frequently performed by obstetricians and gynecologists, provides a permanent solution for gynecological conditions in which medication or other organ-preserving medical methods are insufficient. Hysterectomy, which plays a role in the definitive treatment of chronic complaints that profoundly affect the patient’s general health and quality of life, can now be planned very safely with the help of advanced surgical technologies. This intervention aims to restore the patient’s physical health and enable her to take a step toward a more comfortable life.

For Which Medical Reasons Is Hysterectomy Performed?

The main conditions that may lead to hysterectomy and cause physicians to make a surgical decision are as follows:

• Fibroids
• Adenomyosis
• Pelvic organ prolapse
• Persistent uterine bleeding
• Precancerous cellular changes
• Gynecological cancers

The vast majority of surgeries are performed to treat non-cancerous conditions, referred to medically as benign diseases. The most common problem in this group and the one that most frequently leads to surgery is fibroids. Fibroids are benign tumor structures arising from the thick muscle tissue of the uterus. Although they are present in many women, they may sometimes grow silently for years without causing any discomfort. However, in some cases, they reach enormous sizes or are located in a way that directly presses toward the inner lining of the uterus. This condition may cause excessively heavy and clot-filled menstrual bleeding, depletion of the body’s iron stores, and severe anemia to an extent that interferes with daily life. In addition, growing fibroids can create a significant mass effect in the abdomen and compress surrounding organs. When they press on the bladder, they may cause a constant urge to urinate, and when they press on the intestines, they may cause chronic constipation. When these problems cannot be overcome with medication, surgical intervention becomes necessary.

Adenomyosis is a condition in which the tissue lining the inner layer of the uterus and shed each month with bleeding grows into and becomes embedded within the thick muscular wall of the uterus. Since it does not form a clearly defined lump like fibroids, it is anatomically not very possible to remove only the diseased tissue. During each menstrual period, these displaced tissues inside the uterine muscle also attempt to bleed, and because they are trapped within the muscle tissue, they can cause extremely severe menstrual pain and chronic pelvic pain. For women who have completed family planning and do not benefit from medical suppression treatments, removal of the uterus is among the main approaches that can break this severe cycle of pain.

Due to factors such as advancing age, difficult vaginal deliveries, or genetically weak connective tissue, support from the pelvic floor muscles may weaken. As a result of this loss of support, the uterus, bladder, or intestines may prolapse outward through the vagina. This condition, called pelvic organ prolapse, disrupts the patient’s urinary continence functions and seriously restricts participation in social life. In such cases, hysterectomy is often also required in order to repair the anatomical structure and suspend the tissues upward. In addition, in early-stage cervical cancers, endometrial cancers, and specific precancerous conditions in which cellular structure has deteriorated, complete removal of the uterus is a necessary step in accordance with oncological principles.

What Are the Types of Hysterectomy According to the Scope of the Surgery?

Depending on the type and extent of the disease and the patient’s anatomical structure, which parts of the uterus will be removed or which tissues will be preserved may vary during surgery. The main surgical types performed are listed below.

• Total hysterectomy
• Subtotal hysterectomy
• Radical hysterectomy

Total hysterectomy is currently the most frequently performed surgical method for benign diseases and is considered the standard approach. In this operation, the body of the uterus and the cervix are removed together as a single unit without being separated. Removing the cervix from the body is also a highly advantageous approach because it largely eliminates the patient’s possibility of developing cervical cancer in later years. After this method is applied and the patient recovers, the need for patients to continue routine cervical cancer screening (smear test) usually ends.

Subtotal hysterectomy is a method in which only the upper body of the uterus is cut and removed, while the cervix is left anatomically in place in the lower region. Although it was performed much more frequently in the past, today it is generally not the first choice except in certain necessary situations. For example, if there are very dense adhesions in the abdomen due to previous surgeries or diseases, or if reaching the lower pelvic region poses a major risk to the bladder or urinary tract because of severe obesity, the physician may choose this method in order to keep the surgery shorter and safer. However, because the cervical tissue remains in place, some patients may continue to experience mild spotting on days corresponding to their menstrual periods. More importantly, because the risk of cervical cancer is not eliminated, patients who undergo this operation must continue regular smear screening tests carefully throughout their lives.

Radical hysterectomy is a very comprehensive and extended operation performed in gynecologic oncology, mainly for the surgical treatment of cervical and endometrial cancers. The aim in this process is not only to remove the uterus; together with the uterus and cervix, the broad supporting connective tissues surrounding the uterus, the upper parts of the vagina, and the surrounding pelvic lymph nodes are also removed within safe oncological margins. Because it is performed to clear the pathways through which cancer cells may spread, it requires much deeper and more detailed dissection than other methods. Therefore, the likelihood of conditions such as lymph fluid accumulation, swelling in the legs, or temporary difficulty urinating after the operation is somewhat higher compared with standard surgeries.

Are the Ovaries and Fallopian Tubes Preserved During Hysterectomy?

One of the most important issues jointly evaluated by the physician and patient during the decision-making process is planning what will be done not only with the uterus but also with the ovaries and fallopian tubes located on both sides of the uterus. The main factors determining the fate of these organs are as follows:

• Patient’s age
• Menopausal status
• Family history of cancer
• Characteristics of the current disease

If the patient is already in menopause, the reproductive function of the ovaries and their production of estrogen have already largely ended. With advancing age, the likelihood of unwanted cellular changes occurring in otherwise silent ovarian tissue also increases. For this reason, in hysterectomy operations performed after menopause, removal of both ovaries and fallopian tubes together with the uterus is considered a standard approach as a preventive measure.

However, if the patient has not yet entered menopause and is a young woman under the age of fifty, the surgical approach changes completely. In young women, the ovaries continue to produce many important hormones, especially estrogen. These hormones support cardiovascular health, preserve bone density, nourish the skin, and maintain the body’s overall balance. If the ovaries are also removed while the uterus is being removed for a benign problem such as fibroids, the patient will suddenly enter surgical menopause when she wakes from the operation. Sudden menopause may bring not only severe hot flashes but also the risk of early osteoporosis and heart disease. In order to prevent these medical disadvantages, the aim in young patients is to leave the ovaries in place and preserve them.

Even when the ovaries are carefully left in place, removal of both fallopian tubes, which carry the egg to the uterus, is a very common and recommended practice in modern medicine. Comprehensive scientific studies conducted in recent years have shown that a significant proportion of high-grade ovarian cancers, which are among the cancers women fear most, actually begin not directly in the ovaries but in cells located at the fimbrial ends of the fallopian tubes. Therefore, during hysterectomy, removing only the tubes while preserving the ovaries is a critical preventive maneuver that does not disturb the patient’s hormonal balance in any way while significantly reducing the future risk of developing ovarian cancer.

What Preparations Are Made Before Hysterectomy?

A safe and smooth surgical process depends on a meticulous preparation phase that begins long before entering the operating room. The main evaluation steps patients undergo before the planned operation are as follows:

• Comprehensive blood tests
• Endometrial tissue sampling
• Radiological imaging
• Treatment of anemia
• Infection prevention protocols

Especially in patients around the menopausal period who present with irregular or heavy bleeding, even if the problem is thought to be only a benign fibroid, it is very important before surgery to take a tissue sample from inside the uterus using a thin cannula or to examine the uterine cavity with camera systems called hysteroscopy. The main objective here is to detect before surgery whether there is a silently progressing cellular abnormality within the uterus, such as a malignant or precancerous condition. Having this clear information before the operation makes it possible to determine the boundaries and method of surgery correctly and protects the patient from undergoing incomplete or inadequate oncological surgery. At the same time, in minimally invasive operations, the uterus may sometimes need to be fragmented in order to remove it from the body; if there is an occult cancer, this fragmentation process may cause the disease to spread inside the abdomen, so obtaining a tissue sample in advance eliminates this risk.

In patients who have had anemia for a long time due to heavy menstrual bleeding, optimizing blood values before the operation is essential. If hemoglobin levels are dangerously low, intensive intravenous iron supplementation or medical suppression treatments that temporarily stop bleeding are applied during the weeks before surgery to raise blood values to normal ranges. When the body’s blood reserves are adequate, the need for external blood administration (blood transfusion) during surgery and the risk of additional strain on the heart are minimized. In addition, because a drop in the patient’s body temperature in the operating room may weaken blood clotting mechanisms and increase bleeding during surgery, patients are kept warm throughout the operation using special heated blanket systems, and strong antiseptic preparations are applied against infections.

Which Surgical Methods Are Used to Perform Hysterectomy?

With the rapid advancement of surgical technologies, hysterectomy operations have moved beyond a single technique and now offer a broad range of options that can be shaped according to the patient’s needs. The surgical methods currently used are as follows:

• Abdominal hysterectomy
• Vaginal hysterectomy
• Laparoscopic hysterectomy
• Robotic hysterectomy
• vNOTES surgery

Abdominal hysterectomy is the traditional method, also commonly known as open surgery. The abdominal cavity is reached through either a horizontal incision resembling a cesarean section scar in the lower abdomen or a vertical incision extending downward from the navel. Because it allows the surgeon to work with a wide field of view and tactile sensation, it was the most frequently used method in the past. Today, it continues to be used mainly in extremely enlarged uteri with giant fibroids, severe adhesions connecting intra-abdominal tissues, or advanced-stage extensive cancer surgeries. However, because the skin, fat, and muscle layers of the abdominal wall are cut, the level of postoperative pain is higher, hospital stay may be prolonged, and there is a future risk of hernia formation at the incision site.

Vaginal hysterectomy is a natural method in which all procedures are carried out entirely through the vaginal canal without making any incision in the abdomen. It is the technique with the fastest physiological recovery, especially in patients with uterine prolapse whose vaginal canal is wide enough for surgical instruments. The absence of any abdominal sutures greatly increases postoperative comfort. However, if the patient’s uterus is too large to be removed through the vagina, if the patient has never had a vaginal birth, or if there are adhesions in the abdomen due to previous surgeries, the applicability of this method may be limited because inability to clearly visualize the upper organs may create surgical risk.

Laparoscopic hysterectomy forms the basis of the modern minimally invasive surgical concept. Three or four small openings, generally ranging between five and ten millimeters, are made in the abdominal wall. The abdominal cavity is inflated with safe carbon dioxide gas and expanded like a tent, and high-resolution long cameras are inserted inside. These systems provide the surgeon with a highly detailed map by magnifying tissues, tiny blood vessels, and nerve networks to a degree that cannot be seen with the naked eye. Thanks to special energy devices that simultaneously seal and cut tissues, the amount of bleeding is kept at very low levels. After the uterus is separated from the surrounding tissues, it is generally removed through the lower route, via the vagina, and the top of the vagina is closed with absorbable sutures from inside.

Robotic hysterectomy is a computer-assisted and much more advanced technological form of laparoscopy. The surgeon performs the operation not directly beside the patient but while seated at a special console in the operating room. The robotic arms placed in the patient’s abdomen imitate the wrist movements of the human hand at much wider angles, rotating around their own axes and completely without tremor. It provides the surgeon with major ergonomic comfort and superior maneuverability, especially in patients with severe obesity, in complex endometriosis cases that require working in very deep areas, or in cancer cases that require meticulous removal of lymph nodes.

Natural orifice surgery called vNOTES is a highly innovative approach that has become increasingly popular in recent years. Unlike laparoscopy, not even small openings are made in the abdominal wall. Endoscopic cameras and thin long instruments are directed into the abdomen through a special multichannel silicone port placed in the vaginal canal. In short, the incision-free and scar-free feature of vaginal hysterectomy is combined with the excellent camera visualization of organs provided by laparoscopy. The absence of any surgical scar on the patient’s abdomen after the operation and extremely low pain scores are among the reasons this method is frequently preferred by patients.

What Are the Differences Between Minimally Invasive Hysterectomy Methods and Open Surgery?

The general trend in the surgical world is to achieve maximum benefit while treating the disease with the least possible damage to the patient’s healthy tissues. In this context, minimally invasive methods have many advantages compared with traditional open surgery. The most notable differences are as follows:

• Much lower amount of bleeding
• Absence of large surgical incisions in the abdomen
• Reduced postoperative pain
• Significantly shorter hospital stay
• Rapid return to daily and social life
• Cosmetically satisfactory results

In open surgery, tissue trauma is greater because the layers of the abdominal wall are cut widely. This causes the patient to experience much more pain after surgery when getting out of bed, going to the toilet, coughing, or moving. In laparoscopic, robotic, or vNOTES surgeries, the integrity of the abdominal wall is largely preserved because only a few millimeter-sized incisions are made or no incision is made at all. Thanks to advanced camera systems and vessel-sealing instruments, blood loss during surgery generally remains at much lower levels than in open surgery.

There are also significant differences between open and minimally invasive methods in terms of hospital stay. After open surgery, patients are generally kept under observation in the hospital for several days because of pain control and wound care, whereas patients undergoing minimally invasive surgery are often able to be discharged the day after the operation. Similarly, while tissue healing and return to normal social life, light exercise, driving, or work after open surgery may sometimes take up to one and a half months, patients undergoing minimally invasive surgery can generally return to this normal routine much more comfortably within a much shorter period of one to two weeks. Of course, every patient’s weight, previous surgeries, and uterine size may not be suitable for minimally invasive surgery; the method to be applied is decided together with the patient after the physician’s detailed examination.

What Happens During the Recovery Process After Hysterectomy?

The hours spent in the hospital after surgery and the subsequent rest period at home are the most critical phases determining the quality of recovery. The main factors considered during the early recovery period are as follows:

• Getting out of bed and walking early
• Preventing blood pooling in the legs
• Supporting bowel function
• Protecting the vaginal suture line
• Being cautious with physical activities

Within the first six to eight hours after surgery, it is very important for patients to get out of bed and walk around the room or corridor under the supervision of a nurse and companion. This early walking prevents blood flow in the leg veins from slowing down and helps prevent dangerous conditions such as blood clots traveling later. At the same time, it helps bowel movements, which have nearly stopped under the effect of anesthesia medications, to restart and relieves severe abdominal bloating and gas problems that may occur. In minimally invasive surgeries, the gas introduced into the abdomen may press on the diaphragm muscle after surgery and cause temporary aching in the right or left shoulder region during the first few days. As patients move and walk, body tissues absorb this gas and relief occurs.

During the rest period at home, especially in the first two to four weeks, light pink, brown, or sometimes yellowish discharge in the form of slight leakage from the vagina is expected. This is a normal process indicating that the suture line at the top of the vagina, where the uterus was removed, is healing internally and that the absorbable sutures in the wound area are gradually dissolving and being discharged. During this period, it is very important not to place pressure on the internal sutures; patients should avoid constipation, drink plenty of water, eat fiber-rich foods, and avoid severe straining during bowel movements. For the same reason, throughout the average six- to eight-week period until healing is complete, it is recommended to avoid heavy housework, lifting heavy loads such as bags or objects, and strenuous exercises that contract the abdominal muscles.

Does Hysterectomy Cause Menopause, Weight Gain, or Sexual Problems?

There are many misconceptions in society about this operation that have no medical basis and are spread by word of mouth. The most common concerns associated with hysterectomy are as follows:

• Fear of premature aging and suddenly entering menopause
• Concern about uncontrolled weight gain after surgery
• Belief that sexual life will be negatively affected

First of all, it should be stated that removal of the uterus alone does not cause the patient to enter menopause. Menopause is a systemic process that begins when the ovaries stop producing hormones, not when the uterus is removed. If the patient is young and her ovaries are preserved during surgery, these organs continue to produce the estrogen hormone needed by the body just as they did before the operation. The fact that the patient no longer menstruates after surgery does not mean that her hormones have ended; it only means that the uterine tissue that would have bled in response to those hormones is no longer present. Therefore, young patients who have had their uterus removed do not experience hot flashes after surgery or age prematurely due to hormone deficiency. Even if the ovaries are removed due to a medical necessity, these symptoms can be easily controlled with individualized hormone supplementation planned by the physician.

Postoperative weight gain is also not a direct physiological result of the operation. Removal of the uterus from the body does not have an effect that slows metabolism. Weight gain observed in some patients is generally related to prolonged inactivity after surgery, continuous resting at home, stress, or changes in eating habits. Once the recovery period is complete, patients who return to their routine life, eat a balanced diet, and walk regularly can easily maintain their weight balance.

Concerns about sexuality are also mostly unfounded. After surgery, sexual intercourse is generally restricted for six to eight weeks so that the sutures at the top of the vagina can safely fuse with the tissue and heal. After this rest period is completed and following the physician’s examination, modern surgeries that carefully preserve the anatomical structure generally do not cause loss of sensation or shortening in sexual function. On the contrary, large fibroids, chronic infections, pelvic pain, or the expectation of severe bleeding that existed before surgery may have made sexuality painful and difficult for the woman. Because the fear of bleeding and the source of deep pain are eliminated when the uterus is removed, many patients report having a psychologically more relaxed, comfortable, and peaceful sexual life after surgery.

For Which Symptoms After Hysterectomy Is It Necessary to Consult a Doctor?

Although the recovery process is smooth and safe for most patients, as with every surgical intervention, there are some situations in which patients need to remain alert and seek medical assistance. Important findings that should not be ignored and should be reported to the physician without delay are as follows:

• Unexpected high fever
• Active, heavy, bright red vaginal bleeding
• Foul-smelling, green, or purulent vaginal discharge
• Increasing abdominal pain that does not respond to painkillers
• Sudden swelling, warmth, and redness in only one leg
• Severe burning during urination or inability to urinate

Although mild brown spotting seen on a pad during the early postoperative period is considered normal, fresh, bright red bleeding that exceeds slight leakage and continues as if flowing from a tap may indicate opening of the internal vaginal sutures or accumulation of blood inside the abdomen. Similarly, high fever lasting for days and very foul-smelling discharge may be signs of infection at the wound site or in the pelvic region. Unilateral swelling and tenderness in the legs raise suspicion of a dangerous blood clot forming inside a vein. When such warning signs are noticed, it is extremely important for the patient to seek care at the healthcare institution where the operation was performed or the nearest emergency department without panicking but also without losing time. With early intervention, such complications can be successfully brought under control before they progress, and the patient’s recovery process can safely continue from where it left off. With meticulous surgical planning, patient adherence to recommendations, and proper follow-up, hysterectomy is an extremely effective treatment that can relieve women of complaints that have continued for years.