The scope of vaginal hysterectomy

The impact of obesity on vaginal hysterectomy and laparoscopically-assisted vaginal hysterectomy outcomes: A randomised control trial

OBJECTIVES

This prospective randomised control trial aimed to compare outcome measures of vaginal hysterectomy (VH) and laparoscopically-assisted vaginal hysterectomy (LAVH) in obese vs. non-obese women undergoing hysterectomy for benign uterine conditions with a non-prolapsed uterus. The primary objective of the study was to estimate operation time, uterine weight and blood loss amongst obese and non-obese patients undergoing VH and LAVH. The secondary objective was to determine any difference in hospital stay, the need for post-operative analgesia, intra- and immediate post-operative complications, and the rate of conversion to laparotomy for obese vs. non-obese patients undergoing VH and LAVH.

STUDY DESIGN

A prospective randomised control study was undertaken in the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Women admitted between January 2017 and December 2019 for hysterectomy due to benign conditions, meeting the inclusion criteria set by the unit (vaginally accessible uterus, uterine size ≤ 12 weeks of gestation or ≤ 280gr on ultrasound examination, pathology confined to the uterus) were included in the study. The VH procedures were performed by the residents in training, under the supervision of specialists with large experience in vaginal surgery. All the LAVHs were performed by one surgeon (AC). In addition to the patient characteristics and surgical approach to hysterectomy, operative time, estimated blood loss, uterine weight, length of hospital stay, intra-operative and immediate post-operative complications were also recorded in obese and non-obese patient groups and comparatively analysed.

RESULTS

A total of 227 women were included in the study. 151 patients underwent VH and 76 LAVH, upon randomisation on a 2:1 basis, reflecting the habitual proportion of hysterectomy cases in the Urogynaecology and Endoscopy Unit at CMJAH. No significant differences were found in mean shift of pre-operative to post-operative serum haemoglobin, uterine weight, intra- and immediate post-operative complications, and convalescence period when comparing obese and non-obese patients in both the VH and LAVH groups. There was a statistically significant difference in operating time between the two procedures. The LAVHs took longer compared to the VHs to be performed (62.8 ± 9.3 vs. 29.9 ± 6.6 min in non-obese patients, and 62.7 ± 9.8 vs 30.0 ± 6,9 min for obese patients). All VHs and LAVHs were successfully accomplished without major complications.

CONCLUSION

VH and LAVH for the non-prolapsed uterus is a feasible and safe alternative for obese patients demonstrating similar perioperative outcome measures as non-obese women undergoing VH and LAVH. Where possible, VH should be preferred to LAVH as it is a safe route of hysterectomy, with operation time being significantly shorter.

Formal institutional guidelines promotes the vaginal approach to hysterectomy in patients with benign disease and non-prolapsed uterus

OBJECTIVES

This study was undertaken at the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital to determine if the use of formal guidelines and a standardised surgical technique would increase the rate of vaginal hysterectomy (VH) and result in an overall decline in open abdominal hysterectomy (AH).

STUDY DESIGN

All women admitted between July 2001 and December 2014 for hysterectomy due to benign conditions, meeting the guidelines criteria (vaginally accessible uterus, uterus ≤ 12 weeks size or ≤ 280 g on ultrasound examination and pathology confined to the uterus) were included. The surgical route was determined using the Unit surgical decision tree algorithm. In cases where the pathology was not confined to the uterus or success in VH was uncertain, laparoscopic assisted vaginal hysterectomy (LAVH) was performed. The VH procedures were performed by the residents in training, under the supervision of specialists with large experience in vaginal surgery. In addition to the patient characteristics and surgical approach to hysterectomy, length of hospital stay, intra-operative and immediate post-operative complications were also recorded and analysed.

RESULTS

A year before the initiation of the study, the percentage of all VHs undertaken in the Department was 9.8 % (mainly performed for utero-vaginal prolapse). During the study period, 1143 vaginal procedures (1017 VHs and 126 LAVHs) were performed. The most common indications were cervical dysplasia, uterine fibroids, dysmenorrhoea or abnormal uterine bleeding, adenomyosis, endometrial hyperplasia and chronic pelvic pain. Introducing a formal clinical decision tree algorithm and a standardised surgical technique resulted in an increase in the rate of VH to 48.4 % and overall decline in open AH from 91.2%-51.6%. Thus, the VH/AH ratio increased from 1/9 at the beginning of the study (July 2001) to 1/1 by its end (December 2014). In all cases, VH was performed without the need to convert the vaginal to the abdominal route.

CONCLUSION

The use of institutional guidelines for determining the hysterectomy route and a standardised VH technique resulted in an increased number of performed VHs. This provided an essential opportunity for residents to acquire, improve and maintain the skills required to safely perform VH.

Evidence-based practical guidelines of the International Society for Gynecologic Endoscopy (ISGE) for vaginal hysterectomy

OBJECTIVE

The study was established by the International Society for Gynecologic Endoscopy (ISGE) to provide evidence-based recommendations in the steps that should be undertaken in successfully performing a vaginal hysterectomy for a non-prolapsed uterus.

MATERIAL AND METHODS

The ISGE Task Force for vaginal hysterectomy for the non-prolapsed uterus defined key clinical questions regarding the surgical technique, which led the Medline/PubMed and the Cochrane Database literature search. Identified pertinent articles, published in English from 1997 to 2019, were analysed. The available information was graded by the level of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group approach. The recommendations were developed through multiple cycles of literature analysis and expert discussion.

RESULTS

Six recommendations were established: 1. A circular incision at the level of cervico-vaginal junction is recommended (grade IC). 2. The posterior peritoneum should be opened first (grade IC). 3. Clamping and cutting the uterosacral and cardinal ligaments before or after getting access into anterior peritoneum is recommended (grade IC). 4. Routine closure of the peritoneum during vaginal hysterectomy is not recommended (grade IB). 5. Vertical or horizontal closure of the vaginal vault following vaginal hysterectomy is recommended (grade IC). 6. To insert a vaginal plug following vaginal hysterectomy is not recommended (grade IB).

CONCLUSION

Vaginal hysterectomy for a non-prolapsed uterus should be the preferential route for removing the uterus when hysterectomy is indicated. The ISGE provides evidence-based practical guidelines on how vaginal hysterectomy for non-prolapsed uterus should be undertaken. All efforts should be directed in teaching the surgical technique of vaginal hysterectomy during residency.

Clinical determinants of vaginal and abdominal hysterectomy for benign conditions at the University Teaching Hospital, Yaounde-Cameroon

Background:

Little is known about training and the practice of vaginal hysterectomy in many sub-Saharan Africa countries.

Objective:

The aim of this study was to identify the clinical determinants of choice of hysterectomy route for benign conditions at the University Teaching Hospital in Yaoundé, Cameroon (UTHYC).

Methods:

This was a retrospective cross-sectional study at the UTHYC from January 1, 2000 to December 31, 2008. Non-emergency hysterectomies for benign conditions were divided into two surgical approaches: vaginal and abdominal. Patients’ files and registers were used for data collection. Variables of interest were socio-demographic, reproductive health, and clinical characteristics, including indications and surgical route. Analysis was performed using Epi-Info version 3.5.1. Logistic regression analysis was conducted to determine the association between clinical variables and surgical routes. Odds ratios with their 95% confidence intervals (CI) were calculated. The level of significance was set up at P < 0.05.

Results:

One hundred and sixty-three women who underwent hysterectomy for benign conditions were included in the study. Thirty-seven (22.7%) were by vaginal route and 126 (77.3%) by abdominal route. Indications for hysterectomy were: cervical premalignant lesions, symptomatic uterine fibroids, prolapsed uterus, endometrial hyperplasia, recurrent cervical condyloma, and dysfunctional uterine bleeding. All 61 women with estimated uterine size of more than 12 weeks were operated on by abdominal route. At bivariate analysis, compared to women who had vaginal hysterectomy, factors associated with the choice of abdominal route were secondary/tertiary level of formal education, previous history of laparotomy/caesarean section, premenopausal status, age less than 50 years, and symptomatic uterine fibroids as surgical indication. At multivariate analysis, factors remaining independently associated with the choice of abdominal route were: age <50 years (AOR: 2.99 [1.9–4.71]), P < 0.001); previous laparotomy/cesarean section (AOR: 2.95[2.13–4.08], P = 0.001); premenopausal status (AOR: 1.55 [1.06–2.25]; P = 0.001); and myoma as surgical indication (AOR: 7.49.4[3.2–14.4]; P = 0.0001).

Conclusion:

Less than a quarter of hysterectomies for benign conditions were performed vaginally. All patients with uterine sizes larger than 12 weeks had laparotomy. The determinants of the choice of the abdominal route included age less than 50 years, previous laparotomy/caesarean section, premenopausal status, and fibroid as surgical indication.

Non-decent Vaginal Hysterectomy in Rural Setup of MP: A Poor Acceptance

OBJECTIVE

NDVH is a minimally invasive, safe, effective, and economical surgery. Still AH is preferred for benign gynaecological indications. Our study aims to promote NDVH in all technically possible cases by adequate counselling of the patient.

METHODS

This prospective observational study enrolled 100 women seeking hysterectomy for benign gynaecological conditions (excluding prolapse) in a teaching hospital. Women were counselled on the basis of 'PREPARED' questionnaire to assess their awareness about NDVH and were offered NDVH as the proposed surgery and result is analysed.

RESULTS

We observed that there was a little awareness about NDVH and its outcome among the subjects. Ten out of 100 patients refused to perform NDVH after counselling and underwent TAH. Rest of the 90 patients opted for NDVH. Forty out of 90 patients were aware about NDVH, but they were sceptical about the outcome, and 50 were totally unaware. After applying 'PREPARED' questionnaire and counselling, we could motivate them to accept NDVH. It was successful in all cases except one where laparotomy was done for ovarian artery retraction. With no significant post-operative complications, early return to routine activity and low cost of surgery, all patients were satisfied with surgical outcome and improved quality of life.

CONCLUSION

We conclude that patients accept the surgery with open mind after proper counselling and detailing of the procedure. Most of the abdominal hysterectomy can be converted successfully to NDVH in technically feasible cases by experienced hands so adequate training to gynaecology residents is the need of the time. NDVH is economical to the patient as well as for the healthcare system.

Deciding the route for hysterectomy: Indian triage system

OBJECTIVES

To review the limitations, major complications, and conversion rates associated with non-descent vaginal hysterectomy (NDVH); and develop a scoring system to predict the possibility of successful NDVH.

METHODS

The risk analysis of conversion rates from vaginal to abdominal route while attempting NDVH was applied to formulate a scoring system for the assessment of successful NDVH. Parameters were selected based on Kovacs guidelines to determine the route of hysterectomy.

RESULTS

From April 2005 to December 2008, NDVH was attempted in 364/1,378 women undergoing hysterectomy for benign conditions (Gp-I). Eight out of 364 cases (2.1 %) either had to be converted to the abdominal route or had major complication. Endometriosis and repeated sections had the highest risk. Scoring system was developed based on the risk analysis. Validity of this scoring system was tested in 1,177 women from January 2009 to September 2012 (Gp-II). 460 women with a score of 16 or less underwent NDVH successfully with a conversion rate of 0.2 %.

CONCLUSION

Careful assessment by a simple scoring system can help in deciding the feasibility of performing NDVH.

Optimizing vaginal hysterectomy in women with large volume non-prolapse uteri: a novel minimally-invasive "aneurysm needle clampless technique"

OBJECTIVE

To describe and evaluate the safety and feasibility of a new clampless technique using aneurysm needle for vaginal hysterectomy compared with the standard technique as a less minimally-invasive procedure in women with benign large volume non-prolapse uteri.Study design In a pilot study, series of 46 consecutive women with benign large volume (200-500cm(3)) uterine conditions other than pelvic organ prolapse were planned for vaginal hysterectomy (VH). Patients were divided into 2 groups; group-A (21 women): for whom an (aneurysm needle clampless VH) was performed; group-B (25 women): used as a control (standard VH). Demographic characteristics and peri-operative parameters for both techniques were compared.Results Of the 46 vaginal hysterectomies, 44 were successfully performed (95.7%; 95% confidence interval, 91.6-99.4%). Two (4.3%) conversions were necessary from VH to open surgery [1 case in group A and another case in group B]. There was no statistically significant difference between both groups regarding the demographic data. Preoperative uterine volumes were comparable (232.8mL vs 226.0mL, respectively) (P>.05). The mean operative time was significantly shorter in the clampless VH group compared with the control group (70.14±7.78min vs 79.52±7.41min, respectively) (P=.007). No reported complications in our series.Conclusion Clampless VH using aneurysm needle represents a safe and less minimally-invasivepossible technique in women with benign large volume non-prolapse uteri. It takes a shorter operative.

Observational evaluation of preoperative, intraoperative, and postoperative characteristics in 117 Brazilian women without uterine prolapse undergoing vaginal hysterectomy

BACKGROUND

Despite the introduction of minimally invasive approaches for various benign uterine problems, hysterectomy is often still performed abdominally, but the vaginal route should be used whenever possible. The aim of this study was to identify the preoperative, intraoperative, and postoperative characteristics of women undergoing vaginal hysterectomy in the absence of uterine prolapse.

METHODS

A prospective, descriptive, quantitative, noncomparative study was conducted in 117 women between August 2009 and February 2011 in Petropolis, Rio de Janeiro, Brazil. The women included had a uterine indication for hysterectomy, their surgeries were performed by the same team, and they were followed up for 12 months. An adapted Pelvic Organ Prolapse Quantification system was used to check for uterine prolapse.

RESULTS

The age range of the women was 33-59 years, uterine volume was 300-900 mL, and 73.50% has undergone prior cesarean section. The main indication for hysterectomy was uterine myoma (64.95%), with a surgery time of 30-60 minutes in 55 (59.82%) and 19 (15.98%) cases, respectively. Uterine volume reduction was performed in 41 (35.05%) cases, salpingectomy was the most common associated surgery (81.19%), and anesthesia was subdural (68.37%). Common intraoperative complications included bladder lesions (8.54%), with conversion to the abdominal route being necessary in one case (1.28%), and the most common postoperative complication being vaginal cupola granuloma (32.47%). There was a statistically significant relationship between surgery time and uterine volume (χ(2) = 17.367; P = 0.002).

CONCLUSION

This study suggests that vaginal hysterectomy is a safe surgical procedure in view of its good performance and low complication rate.

Balci technique for suspending vaginal vault at vaginal hysterectomy with reduced risk of vaginal vault prolapse

AIM

The aim of this study was to evaluate the efficacy of a new technique of suspending the vaginal vault at vaginal hysterectomy (VH) for total uterine prolapse.

MATERIAL AND METHODS

This prospective study included 65 patients (group 1) in whom VH was performed using the new technique and 110 patients (group 2) in whom VH was performed using the traditional method. Both groups were followed up for 4 years. The incidences of vaginal vault prolapse (VVP), total vaginal length (TVL) (location of vaginal cuff), intraoperative and postoperative complications and sexual function were compared.

RESULTS

There were no statistically significant differences between the two groups regarding age, parity, body mass index (BMI), blood loss, intraoperative and postoperative complications, and sexual function. One (1.5%) patient had VVP in group 1, whereas 12 (10.9%) patients had VVP in group 2. TVL in group 1 was 8.9 ± 1.2 cm while in group 2 it was 5.9 ± 0.8 cm. The operation times were 57 ± 5 min and 76 ± 9 min in group 1 and group 2, respectively. There was a statistically significant difference between the two groups regarding VVP (P = 0.022), TVL (P < 0.001) and operation time (P < 0.001). The two groups were also compared regarding anterior and posterior prolapse after 4 years: group 1 had less anterior and posterior prolapse (stage II or more) than group 2 (P = 0.041, P = 0.047), respectively.

CONCLUSION

In this new technique, compared to the traditional technique, there was a lower incidence of VVP, greater TVL was achieved and the duration of the operation was shorter.

Transvaginal video-assisted cholecystectomy in clinical practice

BACKGROUND

Transvaginal video-assisted cholecystectomy with rigid instruments is a new procedure that combines natural orifice surgery (NOS) with classic laparoscopy. This hybrid technique requires conventional laparoscopy via an umbilical incision. To date it is unclear if this procedure is safe and feasible in routine practice.

METHODS

We report on a case series of 128 women who consented to transvaginal cholecystectomy. Data, including visual analog scores (VAS), were collected prospectively via a standard digital spreadsheet. Patients completed satisfaction questionnaires within 10 days after discharge from hospital. We report on outcomes, age, body mass index, operating time, complications, pain scores, and patient satisfaction.

RESULTS

In 115 (89.8%) patients the procedure was performed as a transvaginal operation. In 11 women (8.6%), we converted to standard laparoscopy, and in 2 cases (1.6%), we converted to an open procedure. Mean age was 52.4 years (range = 23-78 years) and mean body mass index was 27.8 (range = 18.8-42). Mean operating time was 60.6 min (range = 22-110 min). Other procedures were combined with hybrid cholecystectomy in six cases. Complications following transvaginal access included one vaginal bleeding, one perforation of the urinary bladder, and one superficial lesion of the rectum. In one case the hepatic duct had to be stented due to leakage after the procedure via endoscopic retrograde cholangiography. Mean VAS on day 1 was 2.26 (± 0.31 SEM) and on day 2 it was 1.53 (± 0.35 SEM). In a postoperative questionnaire, 95% of patients indicated that they would recommend this procedure to other patients.

CONCLUSIONS

Transvaginal cholecystectomy is a safe and easy-to-learn procedure. Possible complications are different than those of standard laparoscopic procedures. Trauma to the abdominal wall and scarring is minimal. Postoperative pain scores were not different than those of standard laparoscopy and a high percentage of patients are satisfied with the procedure.

Effectiveness of vaginal hysterectomy for benign conditions in semi-urban hospital: report from Maroua-Cameroon

We assessed the effectiveness of vaginal hysterectomy for benign uterine conditions in Northern Cameroon. This is a case series study of 29 elective vaginal hysterectomies carried out between February 2005 and June 2007 in Maroua, Cameroon. Hysterocele was found as the only or associated indication in 17 (58.6%) patients, symptomatic uterine fibroids in 4 (13.8%) and other indications in 8 (27.6%) patients. The mean duration of the operation was 132 minutes and the mean blood loss at surgery was 150 ml. Twenty-five of the 28 (89.3%) women had less than seven days of hospitalisation. There was a negative correlation (r = −0.45, P = 0.015) between duration of the surgery and the order of operation. One urinary tract and one wound infection were observed. Two patients had conversion to laparotomy. This study has shown that vaginal hysterectomy is a safe and feasible method of hysterectomy in a semi-urban hospital.

Vaginal hysterectomy: dispelling the myths

Despite advances in minimally invasive surgery, most hysterectomies are still performed by laparotomy. The ratio of abdominal to vaginal hysterectomies ranges from 1:1 to 6:1 across North America, and in Canada is approximately 3:1. The SOGC clinical practice guideline on hysterectomy states that the vaginal route should be considered for every hysterectomy; if it is assumed that most surgeons would try to follow accepted guidelines, vaginal hysterectomy is presumably being considered and excluded. The evidence is compelling that vaginal hysterectomy is the approach of choice for benign pathology. The cited contraindications to vaginal hysterectomy are often unsubstantiated. In this commentary we examine the four reasons most often cited for avoiding a vaginal hysterectomy: (1) uterine size, (2) nulliparity and uterine descent, (3) need for oophorectomy, and (4) previous abdominopelvic surgery and extrauterine disease. More research is necessary to evaluate and demystify the barriers to performing minimally invasive hysterectomy. We recommend that preceptorship programs be developed for gynaecologic surgeons in an attempt to decrease the ratio of abdominal to vaginal hysterectomies.

Abdominal vs vaginal hysterectomy: a comparative study of the postoperative quality of life and satisfaction

OBJECTIVE

To compare the short-term results of the quality of life and satisfaction of patients submitted to total abdominal hysterectomy (TAH) and vaginal hysterectomy (VH) for benign uterine disease.

METHODS

Women referred for hysterectomy for uterine myoma were randomized to TAH (n=30) or VH (n=30). The exclusion criteria were uterine prolapse, indication associated surgical procedures and uterine size > or =300 cm3. After a month, follow-up questionnaires had a response rate of 100%, and consisted of an interview with application of SF-36 questionnaire (functional capacity, physical aspect and pain) and evaluation of satisfaction rate.

RESULTS

There were no differences in the patients' mean age, parity, body mass index, preoperative hemoglobin levels and uterine size between groups. Lower postoperative quality-of-life scores were found in the TAH group when compared to the VH group in functional capacity (P=0.002), physical aspect (P=0.008) and pain (P=0.002). The general satisfaction rate with the surgery was similar in the two groups of patients (P=0.147). However, a higher rate of patients submitted to VH would choose the same therapeutic modality (65.5 vs 90%; P=0.021).

CONCLUSIONS

A better postoperative quality of life (functional capacity, physical aspect and pain) and higher satisfaction rate was found in the VH when compared to TAH.

The Hohl instrument for optimizing total laparoscopic hysterectomy procedures

STUDY OBJECTIVE

To evaluate the feasibility of total laparoscopic hysterectomy (TLH) using the Hohl instrument in an initial cohort of patients.

DESIGN

Retrospective cohort analysis (Canadian Task Force classification II-3).

SETTING

Department of Obstetrics and Gynecology, Erlangen University Hospital, Erlangen, Germany.

PATIENTS

Forty-four women underwent the new TLH procedure using the Hohl instrument from May 2004 through January 2005. The laparoscopic approach was used when the patient had undergone more than one previous pelvic abdominal operation and/or had a reduced vaginal capacity. The indications for hysterectomy were symptomatic leiomyoma in 25 patients and hypermenorrhea in 19 patients.

INTERVENTION

Total laparoscopic hysterectomy using the Hohl instrument.

MEASUREMENTS AND MAIN RESULTS

No ureteral or bladder injury occurred in any of the patients. The complication rate during surgery and in the postoperative period was zero. The mean loss of hemoglobin was 1.68+/-0.96 g/dL, the mean operating time was 108+/-21 minutes, and the mean uterine weight was 302+/-121 g.

CONCLUSION

Total laparoscopic hysterectomy using the Hohl instrument simplifies the surgical procedure. The reported technique is an option comparable with laparoscopic-assisted vaginal hysterectomy and may be effective in preventing minor and major complications during TLH.

Vaginal hysterectomy

The vaginal route is a safe, feasible, and patient-friendly method of performing a hysterectomy. Proponents and practitioners of vaginal hysterectomy have widened their indications and decreased the contraindications through liberal usage of debulking, performing oophorectomy, laparoscopic evaluation and trial vaginal hysterectomy. This traditional approach with surgical advances can be used more frequently.