Abstract
Objective
The objective was to evaluate the feasibility and complication rate of vaginal hysterectomy with or without adnexectomy in women with enlarged uteri and/or other considered contraindications to the vaginal route.
Study design
Over a period of 2 years, a total of 204 women underwent vaginal hysterectomy for benign pathology. Normally considered contraindications to the vaginal route were: moderate to excessive uterine enlargement, nulliparity or no prior vaginal delivery, previous cesarean or pelvic surgeries and adnexal pathologies. Laparoscopy was used only if it became necessary. Patients with uterine prolapse were excluded. The clinical outcomes and complication rate were analyzed even with regards to the type of contraindication.
Results
The mean age of the patients was 46.96±4.8 years (range: 38–68). The mean uterine weight was 427.74±254.75 g (range: 150–2,000). The operative time ranged from 30 to 140 min (mean: 61.59±21.80 SD) for vaginal hysterectomy alone, increasing up to 170 min (mean: 83.6±38.28 SD) in case of adnexectomy or laparoscopic assistance. The patient characteristics, the uterine weight and the postoperative results and clinical outcome did not differ among the groups of contraindications. Overall, the complication rate was 9.8%. No patient required a transfusion for surgical blood loss, a return to the operating room or readmission to the hospital. During vaginal hysterectomy, adnexectomy was possible in 90.6% of the cases in which it was indicated (unilateral in 21.8% because of adnexal pathology) and was technically impossible in 9.3%. In 4 cases (1.9%) it was not possible to complete vaginal hysterectomy owing to the presence of thick adhesions obliterating the cul-de-sac, of severe endometriosis or other unforeseen circumstances. In these few cases with a difficult access to the ovaries (2.9% of all VH) or with difficulties in mobilizing the uterus, we resorted to laparoscopy. The pneumoperitoneum was achieved by means of an insufflation tube inserted via the vagina into the abdominal cavity and packing the vagina. Thus, the risks associated to the insertion of the Veress needle were avoided. In all but two cases in which conversion to laparotomy was necessary, laparoscopy was successfully completed.
Conclusions
Vaginal hysterectomy appears to be feasible in about 97% of cases in which this approach would have been judged unsuitable. This figure decreases to 94.2% when oophorectomy is indicated.
Similar content being viewed by others
References
Chapron C, Laforest L, Ansquer Y, Fauconnier A, Fernandez B, Breart G, Dubuisson JB (1999) Hysterectomy technique used for benign pathologies: results of a French multicentre study. Hum Reprod 14:2464–2470
Coulam CB, Pratt JH (1973) Vaginal hysterectomy: is previous pelvic operation a contraindication? Am J Obstet Gynecol 116:252–260
Davies A, O'Connor H, Magos AL (1996) A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy. Br J Obstet Gynaecol 103:915–920
Davies A, Vizza E, Bournas N, O'Connor H, Magos A (1998) How to increase the proportion of hysterectomies performed vaginally. Am J Ostet Gynecol 179:1008–1012
Dicker RC, Greenspan JR, Strauss LT, Cowart MR, Scally MJ, Peterson HB, DeStefano F, Rubin GL, Ory HW (1982) Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The Collaborative Review of Sterilization. Am J Obstet Gynecol 144:841–848
Dorsey JH, Steinberg EP, Holtz PM (1995) Clinical indications for hysterectomy route: patient characteristics or physician preference? Am J Obstet Gynecol 173:1452–1460
Doucette RC, Scott JR (1996) Comparison of laparoscopically assisted vaginal hysterectomy with abdominal and vaginal hysterectomy. J Reprod Med 41:1–6
Doucette RC, Sharp HT, Alder SC (2001) Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol 184:1386–1389; discussion 1390–1391
Gitsch G, Berger E, Tatra G (1991) Complications of vaginal hysterectomy under "difficult" circumstances. Arch Gynecol Obstet 249:209–212
Härkki-Siren P, Sjoberg J, Makinen J, Heinonen PK, Kauko M, Tomas E, Laatikainen T (1997) Finnish national register of laparoscopic hysterectomies: a review and complications of 1165 operations. Am J Obstet Gynecol 176:118–122
Harris WJ (1995) Early complications of abdominal and vaginal hysterectomy. Obstet Gynecol Surv 50:795–805
Heaney NS (1940) Vaginal hysterectomy—its indications and technique. Am J Surg 48:284–288
Johns DA, Carrera B, Jones J, DeLeon F, Vincent R, Safely C (1995) The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital. Am J Obstet Gynecol 172:1709–1719
Kovac SR (1995) Guidelines to determine the route of hysterectomy. Obstet Gynecol 85:18–23
Kovac SR, Cruikshank SH (1996) Guidelines to determine the route of oophorectomy with hysterectomy. Am J Obstet Gynecol 175:1483–1488
Kovac SR, Christie SJ, Bindbeutel GA (1991) Abdominal versus vaginal hysterectomy: a statistical model for determining physician decision making and patient outcome. Med Decis Making 11:19–28
Magos A, Bournas N, Sinha R, Richardson RE, O'Connor H (1996) Vaginal hysterectomy for the large uterus. Br J Obstet Gynaecol 103:246—251
Mazdisnian F, Kurzel RB, Coe S, Bosuk M, Montz F (1995) Vaginal hysterectomy by uterine morcellation: an efficient, non-morbid procedure. Obstet Gynecol 86:60–64
Meikle SF, Nugent EW, Orleans M (1997) Complications and recovery from laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy. Obstet Gynecol 89:304–311
Phipps JH, John M, Nayak S (1993) Comparison of laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy with conventional abdominal hysterectomy and bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 100:698–700
Raju KS, Auld BJ (1994) A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 101:1068–1071
Richardson RE, Bournas N, Magos AL (1995) Is laparoscopic hysterectomy a waste of time? Lancet 345:36–41
Sheth SS (1991) The place of oophorectomy at vaginal hysterectomy. Br J Obstet Gynaecol 98:662–666
Sheth SS, Malpani A (1992) Routine prophylactic oophorectomy at the time of vaginal hysterectomy in postmenopausal women. Arch Gynecol Obstet 251:87–91
Sheth SS, Malpani A (1995) Vaginal hysterectomy following previous cesarean section. Int J Gynaecol Obstet 50:165–169
Unger JB (1999) Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams. Am J Obstet Gynecol 180:1337–1344
Unger JB, Meeks GR (1998) Vaginal hysterectomy in women with history of previous cesarean delivery. Am J Obstet Gynecol 179:1473–1478
Weber AM, Lee JC (1996) Use of alternative techniques of hysterectomy in Ohio, 1988–1994. N Engl J Med 335:483–489
Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB (1994) Hysterectomy in the United States, 1988–1990. Obstet Gynecol 83:549–555
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Paparella, P., Sizzi, O., Rossetti, A. et al. Vaginal hysterectomy in generally considered contraindications to vaginal surgery. Arch Gynecol Obstet 270, 104–109 (2004). https://doi.org/10.1007/s00404-003-0505-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00404-003-0505-x