Pre-operative ultrasonographic evaluation of nongravid, enlarged uteri--correlation with bimanual examination

Is transvaginal ultrasound a worthwhile investigation for women undergoing vaginal hysterectomy?

Vaginal hysterectomy (VH) is the definitive surgical management for uterine prolapse. It is also the preferred route for other pelvic pathology where a hysterectomy is warranted, as it is associated with lower complication rate and faster recovery time. The aim of this study was to determine the usefulness of transvaginal ultrasound scan (TVS) as an investigation prior to vaginal hysterectomy. A total of 103 patients were reviewed over 1 year. Associated gynaecological pathology was found in 46.6% of patients on TVS and this led to a change in planned management in 2.9% of cases. Consequently, preoperative TVS would appear to be a worthwhile investigation.

What is the value of preoperative bimanual pelvic examination in women undergoing laparoscopic total hysterectomy?

OBJECTIVE STUDY: To estimate the value of preoperative bimanual examination of the pelvis in women undergoing total laparoscopic hysterectomy (TLH).

DESIGN

Prospective observational cohort study.

SETTING

Private hospitals and centre.

PATIENTS

One hundred fourteen consecutive women undergoing TLH.

INTERVENTION

All women who were scheduled to undergo TLH from May 2005 through June 2006 had a bimanual examination of the pelvis performed before surgery and the size of the uterus clinically estimated and recorded as gestational equivalents. The operating time, the estimated blood loss (EBL) during TLH, and the final weight of the uterus at histologic study were recorded. Spearman correlation coefficient analysis was used to determine whether there was a correlation between the estimated uterine size before surgery and actual uterine weight, operating time, and EBL.

MEASUREMENTS AND MAIN RESULTS

Of the one hundred fourteen consecutive women eligible for the study, 75 had complete data and therefore were included in the final analysis. The median age was 46 years (range 34-71 years); 22.7% (17/75) had a clinically estimated normal uterus, 10.7% (8/75) had an 8-10/40 uterus, 12% (9/75) had a 10-12/40 uterus, 14.6% (11/75) had a 12-14/40 uterus, 20.0% (15/75) had a 14-16/40 uterus, 9.3% (7/75) had a 16-18/40 uterus, and 10.7% (8/75) had an 18-20/40 uterus. The median operating time was 110 minutes (range 59-240 minutes); the median EBL was 80 mL (range 20-1000 mL); and the median weight of the uterus was 181 g (range 52-1080 g). Histologic diagnoses included leiomyomata in 64.0% (48/75), adenomyosis in 44.0% (33/75), endometriosis in 22.7% (17/75), endocervical polyp in 4.0% (3/75), and normal uterus in 8.0% (6/75). The Spearman correlations between clinical size of the uterus and the weight of the uterus, the EBL, and the operating time were 0.81, 0.33, and 0.29, respectively; that is, the 2 variables tended to increase together. These correlations were all significant (p <.0001, .0044, and .0114, respectively).

CONCLUSIONS

This study showed significant correlation between clinical estimate of uterine size and histologic weight of the uterus, operating time, and EBL in women undergoing laparoscopic hysterectomy. These findings are of great value in preoperative counseling in relation to the risk of bleeding and the potential need for blood transfusion, and in operating room planning.

Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial

OBJECTIVE

The purpose of this study was to compare advantages, disadvantages, and outcomes in patients who undergo vaginal or abdominal hysterectomy for enlarged symptomatic uteri.

STUDY DESIGN

In a prospective, randomized study, 60 vaginal hysterectomies (study group) were compared with 59 abdominal hysterectomies (control group); all of the hysterectomies were performed for symptomatic uterine fibroids from January 1997 through December 2000. We excluded from the study the other common causes of hysterectomy such as prolapse, bleeding, adenomyosis, and endometrial or cervical carcinoma. In both groups, uterine weights ranged from 200 g to 1300 g. For enlarged uteri, vaginal hysterectomies were performed with the use of volume reduction techniques: Intramyometrial coring, corporal bisection, and morcellation. The evaluated parameters included patient age, weight, parity, uterine weight, operative time, blood loss, demand for analgesics, eventual surgical complications, length of admission, and hospital charges. The Mann-Whitney U test and chi(2) tests were applied for statistical analysis. Probability values of <.05 were considered statistically significant.

RESULTS

There were no major differences in patient age, weight, parity, and uterine weight between the two groups. Operative time was significantly lower for the vaginal route as compared with the abdominal route (86 minutes vs 102 minutes, P <.001). No intraoperative complications were noted both in the study and control groups or the control group. Surgical bleeding (expressed by hemoglobin loss) was not significantly different between the two groups. In the postoperative period, we found a higher incidence of fever (30.5% vs 16.6%, P <.05) and demand for analgesics (86% vs 66%, P <.05) in the abdominal group as compared with the vaginal group. Significant advantages of vaginal hysterectomy were a reduction in the hospital stay (3 days vs 4 days, P <.001) and cost.

CONCLUSION

These results should lead to the choice of vaginal hysterectomy as a valid alternative to the abdominal hysterectomy, even for enlarged uteri.