“Hysterectomy by Vaginal Route,” not a Pressure

INTRODUCTION

Hysterectomy is one of the frequently performed surgeries in gynecology worldwide, only second to cesarean section.¹ Even though the vaginal route is associated with lower morbidity, less operative time, and faster recovery. The VALUE study suggested that 67% of surgeons still prefer abdominal approach especially when dealing with pelvic pathology or adnexal removal.²

AIM

The aim of the present study was to determine the feasibility and outcome of nondescent vaginal hysterectomy (NDVH) and to assess the intraoperative and postoperative complications, duration of surgery, and length of hospital stay with NDVH.

MATERIALS AND METHODS

This was a prospective observational study conducted at the Department of Obstetrics and Gynecology at a tertiary care center from July 2012 to July 2014. A total of 256 cases fulfilling the inclusion criteria of definitive indication for hysterectomy for benign gynecological disorders and uterine size up to 16 weeks were included. Women with uterine size more than 16 weeks, stage IV endometriosis, extensive pelvic adhesions, genital tract malignancy, uterine prolapse, and previous pelvic surgery other than sterilization were excluded. The baseline characteristics like age, parity, indication for hysterectomy, uterine size, intraoperative details like type of anesthesia, need for blood transfusion, visceral injury, and postoperative complications were recorded.

Nondescent vaginal hysterectomy was performed under regional or general anesthesia. A circular incision was made around the cervix; urinary bladder was pushed upward after cutting the pubovesicocervical ligament. The anterior and posterior pouches were opened. The uterosacral and Mackenrodt ligaments were clamped, cut, and ligated bilaterally. Then bilateral uterine vessels were secured after clamping, cutting, and ligating. In uteri of larger size with fibroid, adenomyosis, volume reduction techniques of bisection, myomectomy or intramyometrial coring were performed alone or in combination. The third clamps were placed on cornual structures (round ligament, fallopian tube, ovarian ligament) or infundibulopelvic ligament if ovary is removed. The vault was closed after removing the uterus and securing hemostasis.

RESULTS

All 256 patients enrolled in the study were analyzed. The mean age of our patients was 44.4 ± 6.1 years and the mean parity score was 2.4 ± 0.9. The most common indication for NDVH was fibroid uterus. Fibroid uterus was the commonest indication for surgery (Table 1). 89.4% of our patients had uterine size ≤12 weeks and 59% of the patients had uterine volume <200 cm³. In 87.9% of the patients, NDVH was performed under spinal anesthesia. For reducing the volume of the uterus, 48.4% required bisection, 34% had myomectomy, 12.9% required coring, and uterus was removed in 4.7% of the patients. In 57.8% of the patients, bilateral salpingectomy and in 25.8% salpingo-oophorectomy were performed. The mean duration of surgery was 82.5 ± 11.0 minutes. In our study, 4 (1.6%) patients had intraoperative complications: 3 (1.2%) patients with bladder injury were managed by the vaginal route itself and 1 (0.4%) with pelvic hematoma and was converted into laparotomy. The mean blood loss was 330 mL and 1.9% required blood transfusion. The mean hospital stay was 4.9 ± 2.2 days with 57.4% having a duration of stay fewer than 5 days. In the postoperative period, 14 (5.5%) patients had morbidity and 3 of them required prolonged catheterization, 7 patients developed urinary tract infection, and the remaining 4 patients had respiratory tract infection. In the NRS pain scale, the mean pain score was 3.0 ± 0.3.

DISCUSSION

Despite lower morbidity, less operating time for NDVH, a surgeon’s reluctance to perform NDVH may be due to lack of training or fear of increased blood loss when dealing with larger uteri leading to the choice of hysterectomy by other routes. Prior to choosing the route of hysterectomy, physicians should consider how the procedure can be done safely and cost-effectively to fulfill the medical needs of the patient.³

According to ACOG, hysterectomy by the vaginal route is preferred if the size is up to 12 weeks.⁴ However, the size of the uterus alone need not be the criterion as it also depends on the expertise of the surgeon. In our study NDVH was performed up to 16 weeks of size without any complications as we had the expertise of volume reduction techniques like myomectomy, bisection, and coring or a combination of these. Sheth et al. observed that hysterectomy was always feasible through the vaginal route for uteri less than 12 weeks of size and those with more than 12 weeks of size require expertise to perform the surgery. They also observed that the uterine volume up to 300 cm³ was feasible and if more than 300 cm³, extra effort was needed to perform the procedure⁵ and this is on par with our study. We did not include previous surgeries other than sterilization unlike Alokananda et al. study⁶ as the surgeries were performed by surgeons of varying caliber and hysterectomy by other routes were also performed equally.

The decision to electively perform salpingo-oophorectomy should not be influenced by the chosen route of hysterectomy and is not a contraindication to perform NDVH.³ The same principle was followed even in our study and we did not use laparoscopic assistance for any of the patients. ACOG recommends laparoscopic assistance only for the difficult oophorectomy during vaginal hysterectomy.⁷ The failure rate with vaginal route is 3–4%.⁸

The mean duration of surgery was higher when compared to various other studies. This might be due to the surgery being performed by the hierarchy of faculty of varying caliber as this study was conducted in a teaching hospital and also more time was required in patients with large volume of the uterus as we had included uteri up to 16 weeks of size unlike other studies that included up to 12 weeks only. Alokananda in their study observed a mean time of 72 minutes⁶ but Garg et al. required only 41 minutes.⁹ We also observed that the pain score was less and hence the need for analgesics was reduced and promoted early ambulation, reduced postoperative morbidity, and reduced duration of stay in the hospital. Another advantage with NDVH we observed in our study was that the amount of blood loss was considerably less and only 1.9% required blood transfusion. Overall, NDVH is both patient and doctor friendly if patients are selected properly. The limitation of our study was surgery being performed by surgeons of varying caliber and the cost-effectiveness could not be analyzed as the study was conducted in a teaching center.

CONCLUSION

Hysterectomy by the vaginal route is a safe, cost-effective procedure with less morbidity and should be preferred in women requiring hysterectomy for benign gynecological conditions. So hysterectomy by the vaginal route is a pleasure and not a pressure.

REFERENCES

1. Wilcox LS, Koonin LM, Pokras R, et al. Hysterectomy in the united state 1988–1990. Obstet Gynecol 1994;83:549–555. DOI: 10.1097/00006250-199404000-00011.

2. Mc Pherson K, Metcalfe MA, Herbett A, et al. Severe complications of hysterectomy: the VALUE study. BJOG 2004;111(7):688–694. DOI: 10.1111/j.1471-0528.2004.00174.x.

3. ACOG committee opinion no. 444. Choosing the route of hysterectomy for benign disease. Obstet Gynecol 2009;114(5):1156–1158. DOI: 10.1097/AOG.0b013e3181c33c72.

4. American College of Obstetricians and Gynecologists. Precis I, An update in obstetrics and gynecology. CD-ROM.Washington DC 1989.

5. Sheth SS, Shah NM. Pre operative sonographic estimation of uterine volume: an aid in determining the route of hysterectomy. J Gynecol Surg 2002;18(1):13–22. DOI: 10.1089/104240602753595458.

6. Alokananda R, Luna P, Roshan B, et al. Non descent vaginal hysterectomy: a constantly improving surgical art. J Obstet Gynec India 2011;61(2):182–188. DOI: 10.1007/s13224-011-0021-z.

7. The American College of Obstetrics and Gynecologists women’s Health care physicians, Washington DC (USA) 2006. pp. 13–14.

8. Sheth SS. Vaginal hysterectomy. Best Pract Res Clin Obstet Gynecol 2005;19(3):307–332. DOI: 10.1016/j.bpobgyn.2005.01.011.

9. Garg PK, Deka D, Malhotra N. Non descent vaginal hysterectomy for benign conditions. A better proposition than abdominal hysterectomy. Obst Gynae Today 2002;7(6):345–346.