Vaginal Hysterectomy (Nonprolapsed) and Its Impact on a Patient with Gynecologic Menstrual Disorders: Experience in a Tertiary Care Hospital in Bangladesh

Introduction

Hysterectomy is a common gynecologic operation in women all over the world. Although there are numerous benefits of vaginal over abdominal hysterectomy, all large scale surveys of hysterectomy practice have shown that 70%–80% of all hysterectomies are performed abdominally.^1–5 The sole exception to this is the management of uterovaginal prolapse, for which the vaginal route is normally used, but this indication accounts only ∼10% of cases.^2–4 One reason for the predominance of total abdominal hysterectomy (TAH) is that there are numerous relative contraindications to vaginal hysterectomy (VH), the most common being endometriosis, pelvic inflammatory disease (PID), pelvic pain, adnexal disease, adhesive disease, prior pelvic surgery, and enlarged uterine size. ² The available evidence shows that since the widespread introduction of prophylactic antibiotics, VH is associated with less febrile morbidity, less bleeding necessitating transfusion, shorter hospitalization and faster convalescence than abdominal hysterectomy.

As a means of avoiding the need for laparotomy, laparoscopic, ⁶ or laparoscopically assisted VH, ⁷ was introduced as an alternative to abdominal hysterectomy. Subsequent randomized studies have shown that laparoscopic hysterectomy and its derivatives are associated with advantages that are similar to those of VH.^8,9 In an effort to completely avoid the abdominal route, laparoscopy was resorted to in those cases in which, owing to technical difficulties, it was impossible to complete hysterectomy via the vaginal route. However, the operating time for laparoscopic hysterectomy, when compared with that for VH, is considerably longer, and the use of disposable instruments makes it a more expensive procedure without any benefits in terms of reducing postoperative pain or expediting recovery.^10,11

Training and experience in vaginal surgery appear to be the major determinants of the type of hysterectomy women are offered. Experienced vaginal surgeons report overall VH for benign indications of 77 to 88%. ¹²

The rationale for this study is the statement that the vaginal route is to be preferred every time the anatomic conditions allow it, and every time the nature of the lesions to be treated does not contraindicate it.

The aims of this study were to evaluate the feasibility and complication rate of VH in women with enlarged uteri and other traditionally considered contraindications to abdominal surgery.

Materials and Methods

Having obtained the institutional ethics board approval, 300 consecutive women with an enlarged uterus weighing between 280 and 2000 g and/or with the following commonly considered contraindications to vaginal surgery—previous pelvic surgery, history of severe pelvic inflammatory disease, moderate or severe endometriosis, concomitant adnexal masses or other indications to adnexectomy, or limited vaginal access—were enrolled in this prospective study between January 2005 and December 2009. The inclusion criteria for VH were: that the uterine size of the patient did not exceed that equivalent to 20 weeks of pregnancy; the patient had no cardiac or pulmonary diseases; there were no contraindications for lithotomy position; and no extensive adhesion in the pelves.

Exclusion criteria were pelvic prolapse or relaxation, or uteri weighing < 280 g in the absence of other traditional contraindications. Total laparoscopic hysterectomies (10.7% of cases) were scheduled in women with vaginas narrower than two fingers wide and/or with immobile uterus with no lateral mobilization. Indications for VH included: a growing uterus with myomas, abnormal uterine bleeding or menorrhagia attributable to the presence of uterine myomas, and myomas associated with adnexal pathology.

Medical records of the patients were reviewed. Factors examined included: demographic details, uterine weight, indication for operation, operation time, cost, estimated blood loss, hospital stay, intra- and postoperative complication rates, patient recovery time, and histopathology summary.

Informed consents were obtained before surgery. Patients were admitted to the hospital on the day of operation. One g ceftriaxone and 500 g metronidazole were given intravenously as prophylactic antibiotics ∼30 minutes before the operation. The operative time was calculated from the anesthesia chart and included the induction of anesthesia and the positioning of the patients. Complications were classified as:

1. Intraoperative events

The preoperative Hb concentration was compared with that observed on postoperative day 1 and that perioperative Hb concentration change thus calculated. Postoperative fever was considered to be body temperature ≥ 38°C in two consecutive measurements at least 6 hours apart, excluding the first 24 hours. The hospital stay was tracked in whole days.

All analyses were performed using the statistical software for Windows. The operative time ranged from 30 to 90 minutes (mean ± SD, 54.8 ± 12.3).

Results

The indications for hysterectomy were fibroids in 170 cases, dysfunctional uterine bleeding (DUB) in 74 cases, mild PID in 30 cases, endometriosis in 20 cases, and cervical intraepithelial neoplasia (CIN) I mild dysplasia in 6 cases (Table 1).

No patient had uterovaginal prolapse. The mean age of the patients was 42.7 ± 5.8 years (range, 38–60). The mean uterine weight was 265.70 ± 76.9 g (range, 150–2000g).

The mean operative time was 54.50 ± 12.03 minutes increasing up to 120 minutes (mean 53.60 ± 28.28). No patients required a transfusion for surgical blood loss, a return to the operating room theater, or readmission to the hospital (Table 2).

The operative complications are summarized in Table 3.

Two cases of intraoperative hemorrhage and 2 of postoperative infection occurred. In no case was blood transfusion necessary. There was no postoperative vaginal cuff bleeding. Twelve patients had postoperative fever or febrile infections. In no case was repeat surgery or readmission to the hospital necessary. Three intraoperative changes to laproscopic-assisted VH were necessary in patients with a uterus with adenexal pathology and a history including previous pelvic surgery. During VH, adnexectomy was possible in 95% of the cases in which it was indicated. The additional operative time required for removing the ovaries vaginally varied from 10 to 30 minutes (mean, 21.04 minute).

In 1.9% of cases, it was impossible to complete the VH: in 3 cases because of the presence of severe endometriosis and thick adhesions obliterating the cut-de-sac and impeding the access to the pouch of Douglas. Laparoscopy revealed the presence of thick adhesions between the uterine fundus and the abdominal wall at the level of the umbilicus. These were successfully lysed. In all these cases, laparoscopic assistance allowed for completion of the VH.

Discussion

Compared to VH, TAH is associated with an increased morbidity rate,^5,11 a higher complication rate, an increased hospital stay, and a less rapid recovery. Nevertheless, abdominal hysterectomy exceeds VH for benign disease by at least a 3:1 ratio or more in most countries. ⁸ Traditional situations in which vaginal hysterectomy is not possible include an enlarged uterus, a history of pelvic pain or endometriosis, previous pelvic surgery, nulliparity, and indications for oophorectomy. These situations in which vaginal hysterectomy is not possible have been challenged by several authors who have reported doing vaginal hysterectomy in the presence of one or more situations in which vaginal hysterectomy is not possible.^8,9 The indications for vaginal versus abdominal hysterectomy appear to vary from one institution to another and seem to be based more on personal preferences than on the hard evidence reported in the literature. ¹³

The style of practice and surgical experience of the physician have been identified as important variables influencing the decision to perform hysterectomy by a specific technique. ¹⁴ Studies similar to the present suggest that uterine enlargement should not be considered as a contraindication to VH. ¹¹ VH should be considered even in the presence of considerable uterine enlargement. No matter how large the uterus, once the uterosacral and cardinal ligament have been divided, the uterine vessels can be quite easily secured. ¹⁵

Wilcox et al., ¹⁶ analyzing data from the National Hospital Discharge Survey on hysterectomy in the United States from 1988 to 1990, stated that, although prophylactic adnexectomy was performed in 85% of the patients > 45 years of age who underwent abdominal hysterectomy, the same procedure was performed in only 18% of patients who underwent VH. Some authors are advocating oophorectomy as an indication for laparoscopically assisted VH. ¹³ Certainly the indications for ovarian removal should be similar regardless of whether an abdominal, laparoscopic, or vaginal hysterectomy is being performed. ¹⁵ In the present series, prophylactic oophorectomy was scheduled in all menopausal patients but 1 who refused to sign the informed concern for oophorectomy. The rate for total vaginal oophorectomy without laparoscopic assistance (90.6%) is similar to that reported by surgeons with experience in vaginal surgery.^3,14 The more frequent causes of failure were tubo-ovarian adhesions, endometriosis, and vaginal inaccessibility.

Brown et al. ⁸ vaginally completed all the hysterectomies, thus challenging the generally accepted situations in which vaginal hysterectomy is not possible. However, the size of the uterus they reported was smaller than that observed in the present study (>180 g vs > 280 g). In the present series, it was necessary to change to an abdominal route in 2 cases. The failure would have been 6 had there not ben a change to laparoscopy in 4 patients. In the present series, the failure rate was 2.9%. Laporoscopy succeeded in competing with hysterectomy in all cases but it has to be emphasized that, according to the reports of Obermair et al., ¹⁷ change to abdominal hysterectomy because of a technical inability to complete the planned vaginal procedure was associated with an increased operative morbidity.

It was the current authors' earlier experience that laparoscopically assisted VH was intended to replace some abdominal hysterectomies. Since then, it has been apparent that, in most cases, hysterectomy could have been performed vaginally even when risk factors are present. Moreover, in most cases, laparoscopically assisted VH increases costs and operative time, in addition to incurring risks related to the access technique itself, compared to VH. At the moment, the authors do not feel that it is advisable to begin the procedure with a diagnostic laparoscopy and thus expose the patient to the additional risks associated the the insertion of the veress needle and primary trocar. In addition, such an approach may not be necessary in all patients, even in cases with considered contraindications or risk factors, or when oophorectomy is required. In this series, adnexectomy was successfully performed in 90.6% of the cases in which it was indicated.

Conclusions

The current analysis shows that there would be a major impact on the VH rate if gynecologists were trained to perform vaginal surgery when there is no significant uterine prolapse, when the uterus is enlarged, and when oophorectomy is indicated. Better training in vaginal technique would most likely change the current preference for abdominal surgery, and lead gynecologists to considered the vaginal approach as the standard route of surgery. Then, perhaps, the generalist can approach the rates of VH reported by the experts. A target of two thirds of hysterectomies performed vaginally, with the reminder performed abdominally or laparoscopically, depending upon the clinical situation and endoscopic expertise of the surgeon, seems realistic and would greatly benefit patients.