Difficult vaginal hysterectomy

A systematic review of uterine cervical elongation and meta-analysis of Manchester repair

OBJECTIVE

This review aims to consolidate current research on cervical elongation, a common but often overlooked complication in pelvic organ prolapse and hysteropexy procedures. It seeks to define, diagnose, and manage cervical elongation, aiming to establish standardized criteria and strategies to enhance clinical outcomes for this condition.

DATA SOURCES

A comprehensive search of the PubMed/MEDLINE, Cochrane Library, and Web of Science databases was executed utilizing the keywords: "cervical elongation," "long cervix uteri," "Manchester," and "cervical amputation". Data were gathered and organized in an Excel spreadsheet, with the analysis conducted according to each category, methodology, or reference range.

STUDY ELIGIBILITY CRITERIA

All types of study designs with full-text availability, including randomized controlled trials, cohort studies, case-control studies, case reports, and systematic reviews, were considered for inclusion. Included studies were fully accessible in English and focused on the topic of interest. Exclusions were made for studies addressing cervical elongation not pertinent to pelvic organ prolapse, and publications such as secondary analyses, case reports, literature reviews, and opinion papers.

RESULTS

Out of 108 relevant studies, only 63 defined their inclusion criteria; of these, 57 were utilized for the narrative review and 8 were used in a meta-analysis comparing the Manchester operation with vaginal hysterectomy. Magnetic Resonance Imaging offers the highest sensitivity in measuring cervical elongation, its practical limitations and high cost necessitate the use of the more feasible Pelvic Organ Prolapse Quantification System (POP-Q), particularly effective for stage 2 and 3 prolapse cases. The POP-Q point C emerges as a pivotal marker for identifying cervical elongation, with specific measurements indicating the condition's presence. The Manchester-Fothergill procedure presents a viable management option for isolated cervical elongation, showing fewer complications and comparable recurrence rates to vaginal hysterectomy.

CONCLUSION

This review highlights the diagnostic and definitional diversity of cervical elongation within populations experiencing pelvic organ prolapse. It emphasizes the critical role of preoperative cervical evaluation, particularly in patients with uterine descensus for selecting the most appropriate surgical intervention.

Retrospective Analysis of Route Selection for Hysterectomy for Benign Indications at Ochsner Baptist Hospital

Background: Hysterectomy, the most common gynecologic procedure in the United States, can be performed in a number of ways. A shift in surgical practice toward cost-effective and minimally invasive approaches provides an impetus to maximize early training in vaginal surgery for resident physicians.

Methods: A total of 62 abdominal, 303 robotic, and 41 vaginal hysterectomies performed between January 1, 2015 and December 31, 2017 at Ochsner Baptist Hospital in New Orleans, LA, that met inclusion criteria were retrospectively reviewed with a previously published route selection algorithm. We applied the algorithm using preoperative and postoperative data collected via medical record review to determine if our practices favor minimally invasive approaches.

Results: Analysis using preoperative variables identified 152 robotic cases that were vaginal hysterectomy candidates (50.2%). Postoperative analysis of the same cases identified 127 (41.9%) vaginal hysterectomy candidates. Among abdominal cases, 37 (59.7%) called for a less invasive approach by preoperative findings: 7 (11.3%) vaginal and 30 (48.4%) laparoscopic. The algorithm sorted only 25 of the 62 abdominal cases (40.3%) to the abdominal approach.

Conclusion: Use of a hysterectomy route selection algorithm preoperatively improves identification of candidates for minimally invasive hysterectomy.

Completion of vaginal hysterectomy by electro surgery using anteroposterior approach in benign cases faced with obliterated posterior cul-de-sac

Background

Obliterated posterior cul-de-sac has been a real surgical challenge during vaginal hysterectomy. The present study demonstrates an anteroposterior approach to accomplish the vaginal hysterectomy in cases faced with an obliterated posterior cul-de-sac.

Methods

In a retrospective study in private setup, 51 consecutive cases with obliterated posterior cul-de-sac during vaginal hysterectomy due to severe benign pelvic adhesions were studied to know the feasibility of the anteroposterior approach. The upper limit of uterus size was that of 16 weeks of gestation.

Results

Vaginal hysterectomy was completed in 49 (96.08%) cases with obliterated posterior cul-de-sac due to severe benign pelvic adhesions. Two (3.92%) cases needed laparoscopic assistance to complete vaginal hysterectomy. Mean operation time was 109.92±40.13 (45-217) minutes due to the need for careful separation of adhesions from the uterus and indicated additional procedures. Mean weight of specimen uterus was 162±106.51 (40-460) grams. There was no major intra- or postoperative morbidity.

Conclusion

Completion of vaginal hysterectomy was feasible using the anteroposterior approach in most of the cases with obliterated posterior cul-de-sac due to severe benign pelvic adhesions.

Determining Optimal Route of Hysterectomy for Benign Indications: Clinical Decision Tree Algorithm

OBJECTIVE

To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy.

METHODS

A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated.

RESULTS

Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P<.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P<.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years.

CONCLUSION

When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.

Distance From Cervicovaginal Junction to Anterior Peritoneal Reflection Measured During Vaginal Hysterectomy

OBJECTIVE

To quantify the distance of the dissection plane from the cervicovaginal junction to the anterior peritoneal reflection for vaginal hysterectomy.

METHODS

This is a descriptive study examining the dissection plane for anterior colpotomy in 22 surgical patients undergoing vaginal hysterectomy and in nine cadaver specimens. Intraoperatively, the distance from the vaginal incision to the anterior peritoneal reflection was measured on the uterus after removal. In nine of these patients, this distance was also measured before anterior peritoneal incision. Embalmed cadavers with intact pelvic viscera were dissected and the distance of the same dissection plane was measured.

RESULTS

Median (interquartile range) surgical patient age was 51.5 (42-63) years and the main surgical indications were abnormal uterine bleeding and pelvic organ prolapse. In these patients, the median (interquartile range) distance from cervicovaginal incision to anterior peritoneal reflection was 3.4 (2.6-3.7) cm. In cadavers, the median (interquartile range) age was 81 (72-86) years with a measured distance of 2.7 (2.4-2.9) cm.

CONCLUSION

When performing a vaginal hysterectomy, surgeons can expect a median (range) dissection distance of 3.4 (1.8-4.6) cm from initial incision to the peritoneal reflection for anterior colpotomy.

Hysterectomy for pelvic organ prolapse: indications and techniques

Pelvic organ prolapse (POP) is the third most common indication for hysterectomy. Although the techniques for hysterectomy do not differ for prolapsed versus nonprolapsed uteri, there are special considerations when performing a hysterectomy for POP. It is important to remember that a hysterectomy is not sufficient treatment for POP; subsequently after the uterus is removed attention should be paid to correcting the vaginal prolapse. A midurethral sling should be considered for all patients undergoing vaginal prolapse surgery to prevent or treat urinary incontinence.

Comparative analysis of different laparoscopic hysterectomy procedures

PURPOSE

To compare the antecedent gynecological characteristics, indications for, and complications associated with, the different laparoscopic approaches to hysterectomy, in women with benign gynecological conditions.

METHODS

A retrospective cohort study of 957 patients who underwent laparoscopic supracervical (LSH), total (TLH), and assisted vaginal (LAVH) hysterectomies between January 2003 and December 2009.

RESULTS

Among 957 LH, 799 (83.5%) were LSH, 62 (6.4%) TLH, and 96 (10.1%) LAVH. Demographic characteristics were not different among the groups. Antecedent gynecologic conditions that were associated with the type of laparoscopic hysterectomy (LH) performed were: postmenopausal bleeding [LAVH vs. LSH, odds ratio (OR) 2.20; 95% confidence interval (CI) 1.04-4.65], previous pelvic surgery (TLH vs. LSH, OR 1.92; CI 1.05-3.52), previous cesarean delivery (LAVH vs. LSH, OR 0.39; CI 0.21-0.76), and prior hysteroscopy (LAVH vs. LSH, OR 0.29; CI 0.16-0.50). Preoperative diagnoses that were associated with the choice of LH were: menometrorrhagia (LAVH vs. LSH, OR 0.23; CI 0.14-0.38; TLH vs. LSH, OR 0.50; CI 0.26-0.98), uterine fibroids (LAVH vs. LSH, OR 0.25; CI 0.15-0.41), endometrial hyperplasia (TLH vs. LSH, OR 5.5; CI 2.04-14.84), and cervical dysplasia (TLH vs. LSH, OR 17.1; CI 6.83-42.79; LAVH vs. LSH, OR 8.05; CI 3.05-22.06). Estimated blood loss, operating time, and length of hospital stay were significantly reduced with LSH.

CONCLUSION

Antecedent gynecological history and the indications for surgery were associated with the type of LH performed in our institution. LSH was the most common approach and was associated with significantly less morbidity.