ORIGINAL RESEARCH A Randomized Comparison of Total or Supracervical Hysterectomy: Surgical Complications and Clinical Outcomes Lee A. Learman, MD, PhD, Robert L. Summitt, Jr, MD, R. Edward Varner, MD, S. Gene McNeeley, MD, Deborah Goodman-Gruen, MD, Holly E. Richter, PhD, MD, Feng Lin, MS, Jonathan Showstack, PhD, Christine C. Ireland, MPH, Eric Vittinghoff, PhD, Stephen B. Hulley, MD, MPH, and A. Eugene Washington, MD, MSc for the Total or Supracervical Hysterectomy (TOSH) Research Group* OBJECTIVE: To compare surgical complications and clinical outcomes after total versus supracervical abdominal hys- terectomy for control of abnormal uterine bleeding, symp- tomatic uterine leiomyomata, or both. METHODS: We conducted a randomized intervention trial in four US clinical centers among 135 patients who had abdominal hysterectomy for symptomatic uterine leiomy- omata, abnormal uterine bleeding refractory to hormonal treatment, or both. Patients were randomly assigned to receive a total or supracervical hysterectomy performed using the surgeon’s customary technique. Using an inten- tion-to-treat approach, we compared surgical complica- tions and clinical outcomes for 2 years after randomization. RESULTS: Sixty-eight participants were assigned to supra- cervical hysterectomy (SCH) and 67 to total abdominal hysterectomy (TAH). Hysterectomy by either technique led to statistically significant reductions in most symptoms, including pelvic pain or pressure, back pain, urinary in- continence, and voiding dysfunction. Patients randomly assigned to SCH tended to have more hospital readmis- sions than those randomized to TAH, but this difference was not statistically significant. There were no statistically significant differences in the rate of complications, degree of symptom improvement, or activity limitation. Partici- pants weighing more than 100 kg at study entry were twice as likely to be readmitted to the hospital during the 2-year follow-up period (relative risk [RR] 2.18, 95% confidence interval [CI] 1.06, 4.48, P  .034). CONCLUSION: We found no statistically significant differ- ences between SCH and TAH in surgical complications and clinical outcomes during 2 years of follow-up. (Obstet Gynecol 2003;102:453– 62. © 2003 by The Amer- ican College of Obstetricians and Gynecologists.) Hysterectomy remains the most common major opera- tion performed on nonpregnant women in the United States, with over a half million procedures each year. 1 Before cervical cytology screening was introduced as an effective method for preventing cervical cancer, gynecol- ogists routinely removed the nondiseased cervix at the time of hysterectomy to prevent cancer of the cervical stump. 2 Consequently, total hysterectomy (removal of both the corpus uteri and cervix uteri) was the usual procedure, and subtotal or supracervical hysterectomy (SCH) was reserved for rare clinical circumstances in which cervical removal presented undue risks to the patient. Uncontrolled studies have associated total hysterec- tomy with difficulties in sexual functioning, pelvic sup- port, and urinary problems. 3–6 Concerns over these outcomes have fueled an increase in patient and clinician interest in SCH during the past decade. Between 1988 and 1998, the rate of total abdominal hysterectomy (TAH) in Denmark decreased by 38% and the rate of SCH increased by 458%. 7 In the United States the rates of TAH and SCH in New York State showed a similar pattern, 8 although TAH is still considerably more com- mon. Proponents of SCH argue that creating the cervico- vaginal plane may damage nerve structures important to bladder and sexual function, that removing the cervix From the Departments of Obstetrics, Gynecology and Reproductive Sciences, Epidemiology and Biostatistics, and Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California; University of Tennessee, Memphis, Tennessee; Wayne State University, Detroit, Michigan; University of California, San Diego, La Jolla, California; University of Alabama, Birmingham, Alabama This project was supported by grant number UO1 HS09478 from the Agency for Health Care Research and Quality. *See Appendix for a list of all participants. 453 VOL. 102, NO. 3, SEPTEMBER 2003 0029-7844/03/$30.00 © 2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier. doi:10.1016/S0029-7844(03)00664-1