Radical or simple hysterectomy? U of T researcher says post-operative sexual health must be considered

For people with low-risk, early-stage cervical cancer, a simple hysterectomy provides improved bladder function and sexual health compared to a radical hysterectomy, says a University of Toronto-led international research team — and both procedures have similar cancer outcomes.

The team’s study, recently published in the Journal of Clinical Oncology, is the basis for a new international standard of care for people with early-stage cervical cancer.

Led by Sarah Ferguson, a gynecologic oncologist at Princess Margaret Cancer Centre and a professor of obstetrics and gynaecology at U of T’s Temerty Faculty of Medicine, the researchers compared outcomes between patients undergoing a simple versus radical hysterectomy over a three-year period.

Participants in the SHAPE randomized controlled trial were selected for their low-risk profiles, with small tumours of less than two centimetres. Ferguson described the cohort as “a young population with low cancer burden” who had a good quality of life overall.

For the primary outcome, the study found that simple hysterectomy to remove the uterus and cervix was non-inferior to radical hysterectomy for cancer outcomes. However, those who received a radical hysterectomy — which also removes the upper vagina and nearby ligaments and lymph nodes — had worse bladder dysfunction. The results for this outcome were published in 2024 in the New England Journal of Medicine.

The secondary outcome was to use validated sexual health questionnaires to evaluate the sexual health of the person after undergoing surgery for cervical cancer, which had never been measured before.

The study found that after a radical hysterectomy, participants reported worse sexual vaginal functioning, which persisted for up to two years. This included worse vaginal lubrication and more pain. There was no difference in ability to obtain orgasm. These changes resulted in less sexual activity and enjoyment.  

The results suggest that physicians should take into consideration negative sexual health outcomes that may result from a radical hysterectomy, and counsel patients of this possible side effect in those that still require the surgery.

Ferguson recently joined the International Journal of Gynecological Cancer (IJGC) podcast to discuss these findings.

“I think we have to be proactive and keep the ovaries in, if it’s reasonable,” she said. “And, even if you don’t think someone should have systemic hormone replacement, at minimum, give local estrogen.”

Ferguson said she always promotes vaginal health with patients following surgery, which includes lubrication during intercourse, vaginal moisturizer and estrogen if needed.

In addition, she notes a possible way to minimize the impact on bladder function or pain from scarring is through pelvic floor physiotherapy sessions.

“It’s really common and accessible as opposed to ten years ago, when it was hard to find them. I really encourage patients to explore that.”

Ferguson admitted she was surprised by the sexual health dissimilarities found between simple and radical surgeries.

“I don’t think, as a surgeon — and this is probably a bias of surgeons in general — that I thought there would be a significant difference. I think most of us felt that it’s transient, it gets better. Maybe I was a bit naïve.”