Hysterectomy for benign uterine pathology is one of the most practiced surgical interventions in women. The advantages of the vaginal approach in terms of morbidity, operative length of time, duration of hospital stay, and global costs were well demonstrated.1–4 Authors report a 70% to 80% uterus extraction success rate of vaginal hysterectomy in the general population.5–9 Some authors consider lack of vaginal delivery as an obstacle to vaginal hysterectomy, especially in cases of an enlarged uterus.7,8 Few reports studied vaginal hysterectomy specifically among patients without previous vaginal deliveries. These reports demonstrated the feasibility of this procedure.10–13 The main objective of this work was to evaluate the feasibility and the complication rate of vaginal hysterectomy in patients without a previous vaginal delivery. The secondary objective was to report the evolution of the surgical approach, and in particular, the role of laparoscopy. This study updates previously published data14 and underlines the place of laparoscopy in our experience.
MATERIALS AND METHODS
We carried out a review of the medical records of patients admitted for hysterectomy in our department between January 1, 1995, and June 6, 2004. The study population constituted all patients lacking previous vaginal delivery undergoing hysterectomy for benign uterine indications (pelvic pain due to adenomyosis or leiomyoma uteri, bleeding that could not be adequately managed with medical treatment, pelvic organ compression, symptomatic leiomyomata) in the exclusion of uterine prolapse.
The following demographic characteristics were analyzed: age, body weight, height, gestational history, parity, history of caesarean delivery and pelvic surgery, menopausal status if any, and hormonal replacement therapy. We also collected the following surgical characteristics: the indication for hysterectomy, the first intention approach (abdominal, vaginal or laparoscopic-assisted vaginal approach), the association with other surgical procedures (bilateral salpingo-oophorectomy, stress urinary incontinence treatment, ovarian cystectomy, etc), the rate of conversion to laparotomy when applicable, the necessity of uterine fragmentation in cases of vaginal extraction, the operative complications, the operative time, and the duration of hospital stay. The procedure was considered as laparoscopic-assisted whenever laparoscopy was carried out (first intention laparoscopy, difficulty of an exclusively vaginal approach or in the management of complications during vaginal hysterectomy). Bilateral oophorectomy was regularly proposed beginning in January 2000 with hysterectomy, after informed consent, in all patients aged older than 48 years. The operative time was measured from the beginning to the end of the hysterectomy. If there was any associated procedure, time was subtracted. The uterus was immediately weighed after its extraction. In the post-operative period, the following data were collected: loss of hemoglobin (difference between the pre and the 24 hours’ post operative levels of hemoglobin), duration of hospital stay, and occurrence of post-operative complications.
The study population was divided into 2 different groups: group 1 included patients with first intention abdominal hysterectomy; group 2 included patients with vaginal hysterectomy further stratified to two subgroups: subgroup 2a without and subgroup 2b with laparoscopic assistance. The abdominal route was the route of choice for very large uteri. Uteri measuring clinically higher than the level of the umbilicus (about 18–20 weeks pregnancy) were considered as an indication for laparotomy. The choice of the route for hysterectomy was reevaluated immediately before the operation by an examination under general anesthesia. If uterine size was judged to be medium or small, vaginal route was always the route of choice. Laparoscopy was indicated in cases of extremely poor vaginal access, suspicion of endometriosis, the need for exploration of an adnexal mass (or adnexectomy at the beginning of the study period), and in cases of previous abdominopelvic surgery. The characteristics of both groups were analyzed. The statistical analysis was carried out using the SPSS (SPSS Inc., Chicago, IL) statistical software. The means were compared by the Student t test and analysis of variance. The proportions were analyzed by the χ2 test and Fisher exact test when needed. Correlations were obtained using the Pearson coefficient. Significance level was set at 0.05. According to the French law, this study did not require IRB approval.
The number of hysterectomies for benign uterine pathology between January 1995 and June 2004 recorded in the Obstetrics and Gynaecology department was 1,369. Three hundred hysterectomies were performed in patients without previous vaginal delivery and were consequently selected as the study population. Group 1 included 73 patients and group 2 included 227 patients, of which 116 were done with an exclusively vaginal approach (2a) and 111 with laparoscopic- assisted procedure (2b) (Fig. 1).
Groups 1 and 2 were comparable for age, weight, height, gravidity, parity, and history of caesarean delivery (Table 1). There were significantly more patients with a history of pelvic surgery in group 2b than in group 2a and group 1 (P=.001). A greater proportion of menopausal women were found in group 2 (P=.04), but there was no statistically significant difference in hormone replacement therapy between group 1 and group 2. Indications for hysterectomy and associated cure of stress urinary incontinence were also similar between the two groups (P=.89).
During the time frame of the study, we noticed a shift in the surgical approach. The rate of abdominal hysterectomies did not decrease significantly over the period (P=.66), but we observed a significant decrease in laparoscopic-assisted hysterectomies and a significant increase in exclusively vaginal hysterectomies (P<.001) (Fig. 2). First intention laparoscopic assistance decreased (r=–0.34; P<.001), whereas secondary laparoscopic-assisted procedures increased (r=0.17; P=.003).
The mean uterine weight was significantly different between group 1 (1,047 g) and group 2 (326 g) (P<.001), whereas no differences were noted in uterine weight between subgroups 2a (313 g) and 2b (347 g) (Table 2). The uterus weight limit for vaginal extraction was estimated at 1,000 g (P<.001) (Fig. 3). The need for uterine fragmentation by the vaginal approach was necessary in 50.7% of cases (Table 2), with no significant difference between subgroups 2a and 2b (52.7% and 48.5%, respectively; P=.58). The results of the histologic examination were not different between groups 1 and 2 (leiomyomata, adenomyosis, or both). Endometrial adenocarcinoma was discovered in two cases and leiomyosarcoma in four cases.
The total rate of conversion to laparotomy was 7.9% (18 patients), and no significant difference was observed between groups 2a and 2b (6.9% and 9.0%, respectively, Table 2). The most common reasons for conversion were excessive uterine volume or a contracted genital tract (50.0%), pelvic adhesions in six cases (33.3%), anesthetic complications (11.1%), and a bladder lesion in one case (5.5%). The reasons of abdominal conversion were different between subgroups 2a and 2b. Whereas the main cause in subgroup 2a was the uterine volume and/or the vaginal accessibility (75.0%), the main cause in subgroup 2b was the laparoscopic evidence of significant pelvic adhesions (50.0%). The mean weight of the uterus among patients who required an abdominal conversion was 909 g. All conversions in the subgroup 2b were decided upon laparoscopic findings.
Successful vaginal hysterectomies were carried out in a total of 69.7% (209 of 300) of patients without previous vaginal delivery. When the vaginal approach was planned, the uterus was effectively extracted by this way in 92.1% of cases (Fig. 1).
The mean operative time was similar between groups 1 and 2, at approximately 120 minutes (P=.13), but the analysis of the subgroups showed that in the subgroup 2b the operative time was significantly greater (mean 160 minutes [50–420 minutes]) than that of group 1 (mean 120 minutes [60–360 minutes]) and subgroup 2a (mean 75 minutes [25–240 minutes]), P<.001. Vaginal hysterectomy (2a) operative time was significantly shorter than the abdominal one (P<.001) (Table 2).
When analyzed by age, the rate of bilateral oophorectomy was similar between groups 1 and 2 (41.7% compared with 32.0%, respectively; P=.8) and between groups 1 and 2b (P=.51) (Table 2). Differences in conservation of ovaries, however, were noted between groups 1 and 2a (41.7% compared with 21.3%, respectively; P=.005) and between the subgroups 2a and 2b (21.3% compared with 43.5%, respectively; P=.005). Bilateral oophorectomy was therefore less often practiced with the exclusively vaginal approach. We observed, however, a significant increase (P<.05) in the rate of bilateral oophorectomy in all groups during the duration of the study, with a progressive increase in prophylactic adnexal removal in group 2a (Fig. 4), which remained significant at the end of the period of the study (P=.014) (Table 2).
The mean blood loss was similar in groups 1 and 2 (1.2 g/dL compared with 1.4 g/dL of hemoglobin, respectively, P=.53) but when stratified into subgroups, blood loss was more significant in subgroup 2b than in subgroup 2a (1.9 g/dL compared with 1.1 g/dL of hemoglobin, respectively; P<.001). The proportions of operative complications were similar between groups 1 and 2 (10.8% compared with 9.2%, respectively; P=.22). Nevertheless, complication rates were more frequent in subgroup 2b that in subgroup 2a (P<.001).
The list of operative complications is summarized in Table 2. Two cases of perioperative hemorrhage attributed to group 2b were in fact cases from group 2a that we treated laparoscopically for suspect hemorrhage of the ovarian pedicle. The secondary laparoscopic assistance done in these cases permitted us to treat the hemorrhage without necessity of abdominal conversion. All bladder lesions healed without further complications after a 5-day catheterization.
The history of previous cesarean delivery was not a significant risk factor for bladder lesions in the vaginal hysterectomy group of this study (P=.051), ie, the exclusively vaginal approach (7.3% of cases) or the laparoscopic-assisted approach (10.0% of cases) (Table 3). No significant difference was noted between subgroups 2a and 2b (P=.59).
The median length of hospital stay was shorter in group 2 than in group 1 (3.8 days compared with 6.2 days, respectively; P<.001). We did not observe any difference in the length of stay between subgroups 2a and 2b (P=.22) (Table 2).
This study shows that nearly 70% of hysterectomies for benign pathology can be performed by vaginal approach, in patients without previous vaginal delivery. In the study population, where 75% were initially planned for vaginal hysterectomies, only 7.9% of the patients required conversion to an abdominal approach. Consequently, 92.1% of procedures were successful. These data are in accord with work that we have already published14 and work published by several authors of smaller series 6,10–12,15 (Table 4). Most of the series published are French as few international reports exist on hysterectomy techniques in patients without previous vaginal delivery, and since the vaginal approach is very common in France.
International publications on hysterectomy techniques usually do not give any details or stratification of parity.7,16–19 Also, laparotomy is still the preferred method of hysterectomy in large international studies.20,21 Our service serves as a school for vaginal and laparoscopic surgery and so vaginal surgery is always preferred to abdominal surgery. In our study, hysterectomies were performed by junior and senior surgeons, but the largest uteri and the shorter operative times were recorded for the most experienced surgeons. This underlines the importance of surgeon’s skill and experience in the success rate of the vaginal route. A further important point is the final examination under general anesthesia that can modify the surgical route.
This work emphasizes a notable evolution in the choice of hysterectomy methods. Indeed, from the year 2000 and beyond, laparoscopic assistance became less frequent as opposed to the exclusively vaginal approach. Abdominal hysterectomy remained constant with time, mainly because of its necessity in the cases of very large uteri. The reduction in laparoscopic assistance was not due to a decrease of uterine volume, but rather to an increase in operative skills. In our previous report,14 the rates of vaginal and laparoscopic assisted hysterectomy were 47.8 % and 52.2%, respectively. These rates have now been inverted. This evolution in time for hysterectomy methods had already been noted by other authors.11 Laparoscopic-assisted hysterectomy is associated with longer operative times compared with the two other methods. It does not offer any advantage on the duration of hospital stay. When compared with the vaginal approach, it does not allow the extraction of larger uteri and it does not reduce the rate of operative complications. However, when used as second intention, laparoscopy is advantageous in treating operative complication (hemorrhage) or a difficult oophorectomy encountered in the vaginal approach.11,16,22–25 First intention laparoscopy may still be indicated in patients with unclear adnexal pathologies, in women with endometriosis for staging and treating associated extra uterine endometriotic lesions, or in patients with history of pelvic surgery and high risk for pelvic adhesions. However, adhesions can often be managed with the vaginal approach.8,26 The absence of vaginal delivery must not be a single indication for laparoscopic assistance, despite some differing opinions.13
Although it was not significant (P=.051), our study signals a potential risk for bladder lesions by using the vaginal approach in women with previous cesarean delivery. This finding has already been reported in other studies.27,28 Some authors, however, did not find that a history of cesarean delivery is a significant risk factor for bladder lesions with vaginal hysterectomy.29 These contradicting results are shown in Table 5. Because of the small number of bladder injuries in patients with previous cesarean delivery, we could not evaluate the effect of previous cesarean deliveries on the risk of bladder lesion. In our practice, laparoscopic assistance does not decrease the risk of bladder lesions (Table 3). Therefore, a history of cesarean delivery does not constitute an indication for laparoscopic assistance (Dhainaut C. Réponse de C. Dhainaut à la lettre de M. Cosson et J.-P. Lucot [letter]. Gynecol Obstet Fertil 2005;33:836).
We did not find a significant difference in conversion to laparotomy between subgroups 2a and 2b. Our indications for abdominal conversion are similar to those reported in the literature,10,30 namely, very large uteri or thick adhesions with impossibility of lyses. Increased uterine volume represents for some authors a limitation to vaginal surgery in patients without previous vaginal delivery, 280 g being the maximal weight accepted for the vaginal route.31 Several authors have confirmed the feasibility of the vaginal hysterectomy with a mean uterine weight being less than this limit.6,8,10,26,32 Other studies however, some of which are prospective, demonstrate that vaginal hysterectomy is possible for larger uteri.11,12,17 The results of our study are in agreement with these mentioned reports, with a mean uterine weight being 326 g (313 g by exclusively vaginal approach and 347 g in the laparoscopic-assisted approach). Using the fragmentation techniques, increased uterine volume does not constitute a limitation for vaginal approach.8,18,19,22,33 This technique permits the vaginal extraction of voluminous uteri without increasing the morbidity of the procedure.18,33,34 In our study, the rate of fragmentation was 50.7%, which is similar to that reported by other authors in nulliparous women or in the general population.30,32 Studies that show lesser fragmentation rates usually deal with lesser uterine weights.8 In our study, we did not observe any complication attributable to uterine fragmentation.
In our study, as well as in previous reports, we were able to perform bilateral salpingo-oophorectomy in higher proportions in laparotomy and in laparoscopic-assisted vaginal hysterectomy than in vaginal hysterectomy.8,10,11,26 With increasing surgical expertise, adnexal removal is practiced more often during vaginal hysterectomy and laparoscopic assistance is only required secondarily in difficult cases. During the study period, we observed a significant increase in the rates of oophorectomy in all study groups. Our belief is that the need for oophorectomy should not point out the approach for hysterectomy. Moreover, oophorectomy is often easier to perform when the uterus is large, because the ligaments and pedicles are stretched (Dhainaut C, Réponse de C. Dhainaut à la lettre de M. Cosson et J.-P. Lucot [letter]. Gynecol Obstet Fertil 2005;33:836).
The rates of operative complications were similar between groups 1 and 2. Singling out the visceral damage and the major operative hemorrhage, the differences are still not significant between the groups (6.8% compared with 7.0%). The observed complications were similar to those reported in the literature6,10–12,32,35 and particularly to those of the eVALuate study,21 a prospective randomized trial comparing different methods of hysterectomy. In this mentioned trial, however, patients enrolled had a maximal uterus size of less than 12 weeks of gestation (mean weight was not precisely measured), and the frequency of vaginal hysterectomy was low. The trial therefore, could not detect a difference between vaginal and laparoscopic hysterectomy for lack of statistical power. Moreover, in the eVALuate study, the few patients without previous vaginal delivery rarely had vaginal hysterectomy.
The length of hospital stay was shorter in group 2 than in group 1. This finding had already been observed in other studies.8,10,11,17,21 We did not find a significant difference in length of stay between subgroups 2a and 2b, as previously described.36
Finally, analyzing the cost, laparoscopy was shown to be more expensive,4 without the advantage in terms of length of hospital stay or reduction of operative complications. On the other hand, the advantages of the vaginal approach over the abdominal one have been already demonstrated in convalescence time, work discontinuation, quality of life, postoperative pain, and overall satisfaction.32,37
This study substantiates the feasibility of vaginal hysterectomy for patients without previous vaginal delivery. In such patients, 70% of hysterectomies are possible using the vaginal approach. Exclusively vaginal or laparoscopic-assisted hysterectomy allows vaginal extraction in 92% of cases without increasing the operative complication rate. The absence of vaginal delivery should not, therefore, be the only indication for laparoscopic assistance. Bilateral salpingo-oophorectomy is also feasible using vaginal approach without a need for laparoscopy in most of cases, and also, it should not delineate the surgical approach. It is preferable to keep the laparoscopic option as second intention when adnexal ablation seems to be difficult by an exclusively vaginal approach. Nevertheless, laparoscopic-assisted hysterectomy should be reserved for limited indications, because it increases the operative length of time and the operative costs without having the advantages in hospital stay or in reducing complications. The advantage of the vaginal approach over the abdominal one was already demonstrated.
The above-mentioned arguments have led us to prefer a vaginal hysterectomy approach, reserving the possibility of a secondary laparoscopic assistance in cases of absolute necessity. We feel that women without previous history of vaginal delivery should be managed in the same manner as women who had given birth vaginally.
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© 2008 by The American College of Obstetricians and Gynecologists.