Hysterectomy in obese women: a comparison of abdominal and vaginal routes

OBJECTIVE: To compare perioperative outcome measures of abdominal and vaginal hysterectomies in obese women. METHODS: We reviewed the charts of all obese women (body mass index more than 30 kg/m(2)) who underwent abdominal or vaginal hysterectomy for benign gynecologic conditions in our institution between 1997 and 2002. Laparoscopically assisted vaginal hysterectomies and hysterectomies with concomitant major pelvic or abdominal surgery were excluded. The rate of operative and postoperative complications, length of hospitalization, operative time, and perioperative change of hemoglobin concentration were analyzed for abdominal hysterectomy and vaginal hysterectomy. RESULTS: The study group consisted of 369 obese women, of whom 189 (51.2%) underwent abdominal, and 180 (48.8%), vaginal hysterectomy. Patient characteristics were statistically comparable between the groups except for uterine weight, which was higher in the abdominal group, and parity, which was greater for women who underwent vaginal hysterectomy (P <.05). After controlling for all the significantly different variables, vaginal hysterectomy resulted in lower incidence of postoperative fever (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.12-0.39), ileus (OR 0.21, 95% CI 0.06-0.75), urinary tract infection (OR 0.21, 95% CI 0.06-0.75), shorter operative time (126.8 +/- 58.7 minutes compared with 109.7 +/- 68.5 minutes) and length of hospital stay (3.5 +/- 1.9 days compared with 1.9 +/- 1.1 days). Seven women (3.7%) who underwent abdominal hysterectomy developed wound infections during their hospital stay compared with none in the vaginal hysterectomy group. CONCLUSION: For obese women, vaginal hysterectomy is superior due to its lower incidence of postoperative fever, ileus, and urinary tract infection and shorter operative time and hospital stay. LEVEL OF EVIDENCE: II-2     

Vaginal hysterectomy for the enlarged uterus

OBJECTIVE: To evaluate the effect of uterine weight on the perioperative outcomes of vaginal hysterectomy for benign gynecological conditions. MATERIALS AND METHODS: The medical records of 312 consecutive women who underwent vaginal hysterectomies for benign gynecological conditions without major pelvic reconstruction at Temple University Hospital between March 1994 and August 1999 were reviewed. 88 women with uterine weights > or =250 g were compared with 224 women with uterine weights <250 g. The risk of perioperative complications, operative time, perioperative hemoglobin change, length of postoperative hospital stay, and readmission were evaluated between the groups. RESULTS: Groups were similar with respect to age, parity, history of previous pelvic surgery and concurrent adnexal removal. Operative time was significantly increased for women with uteri weighing > or =250 g. Women with uterine weight > or =250 g had a higher risk for postoperative febrile morbidity. The risks of all other major complications, perioperative change in hemoglobin concentration, length of stay, and readmission risk were not statistically different between the groups (p < 0.05). CONCLUSIONS: Despite the increased postoperative febrile morbidity and prolonged operative time, women with uteri weighing > or =250 g who underwent vaginal hysterectomy were discharged from the hospital without any increase in other complications when compared to women with a smaller uterus.     

Previous cesarean section. A contraindication to vaginal hysterectomy?

OBJECTIVE: To compare surgical outcomes of vaginal hysterectomy between women who have had one or more cesarean deliveries and those who have not. STUDY DESIGN: A retrospective, chart review study was performed on women undergoing vaginal hysterectomy during a four-year period. Of 275 women who met the study criteria, 104 had a history of previous cesarean deliveries, and 171 did not. The groups were compared for indications for surgery, operative time, length of hospitalization and surgical complications. RESULTS: Previous cesarean delivery did not affect hemoglobin loss, hospital stay or operative time among women undergoing vaginal hysterectomy. The complication rate (either operative or postoperative) was 12.3% among women without a history of cesarean section, 6.8% among those with one, 3.7% among those with two and 11.1% among those with three or more (chi 2 = 2.8, P = .4). The odds for surgical complications were not significantly different between women with one or more prior cesarean deliveries as compared to those without after adjustment for possible confounders. CONCLUSION: Surgical complications with vaginal hysterectomy do not appear to be higher among women with a prior cesarean section as compared to those without a history of such operation.     

A comparison of abdominal and vaginal hysterectomy for the large uterus.

OBJECTIVE: To compare the perioperative outcomes of women with an enlarged uterus (>or=250 g) who had abdominal and vaginal hysterectomies. METHOD: Retrospective study of the perioperative outcomes of 288 consecutive women with an enlarged uterus, of whom 200 underwent an abdominal hysterectomy and 88 a vaginal hysterectomy, all for benign gynecological conditions. RESULTS: Among the perioperative complications, only the risk of ileus was significantly higher in the group that underwent abdominal hysterectomy. Although the need for blood transfusions was similar between the groups, mean perioperative hemoglobin change was significantly lower for women who had the abdominal approach. Vaginal hysterectomy shortened the length of hospitalization significantly but did not affect the operative time. All of these differences remained significant after adjusting for uterine weight (P<0.05). Baseline characteristics were similar between the groups, except for uterine weight. CONCLUSIONS: For women with a uterus weighing 250 g or more, vaginal hysterectomy shortens the hospital stay without significantly increasing perioperative morbidity when compared with the abdominal route.     

Hysterectomies in patients with no history of vaginal delivery. A study of 243 cases

OBJECTIVE: The object of this study was to audit the policy of hysterectomy in nulliparous women in a university hospital. PATIENTS AND METHODS: A retrospective medical records analysis of all hysterectomies performed during an 8-year period. Patients with no history of vaginal delivery were stratified into three groups: group 1, patients who underwent abdominal hysterectomies; group 2, patients undergoing vaginal hysterectomy (2a) or laparoscopy-assisted vaginal hysterectomy (2b). The groups were compared as to demographic data, surgical complications and outcomes. RESULTS: During the study period, there were 243 hysterectomies in patients with no history of vaginal delivery. Among these, vaginal hysterectomies (group 2) were undertaken in 75% (182 patients) and successfully performed in all but 13 patients (7.1%). Mean uterine weight was 943 grams in group 1 and 370 grams in group 2. Abdominal route (group 1) was associated with longer operative time (average: 105 min) than vaginal route (group 2a; 81 min) but shorter operative time that laparoscopy-assisted vaginal route (group 2b; 173 min). There was no significant difference in mean estimated blood loss and complications rates between groups 1 and 2. Hospital stay was shorter in group 2. Laparoscopic assistance was not associated with bigger uteri, neither with fewer complications. DISCUSSION AND CONCLUSION: Nulliparity should no longer be considered a contraindication to vaginal hysterectomy. In such patients, many more hysterectomies should be carried out vaginally and laparoscopic assistance does not offer obvious advantages over the standard vaginal approach.     

Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams

Objectives: The purpose of this study was to compare the surgical outcomes of women with moderately enlarged uteri undergoing vaginal hysterectomy with those of women with uteri of normal size undergoing vaginal hysterectomy. A secondary objective was to investigate the roles of uterine morcellation and laparoscopically assisted vaginal hysterectomy in the treatment of these women. Study Design: Thirty consecutive women during a 2-year period with uterine enlargement to a weight of between 200 and 700 g underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy limited to lysis of adhesions or adnexectomy. These patients with uterine enlargement (group 1) were compared with 160 women with uteri weighing <200 g who also underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy during the same interval (group 2). The 2 groups were compared for total complications, operative time, hospital stay, perioperative hemoglobin concentration change, and use of vaginal uterine morcellation and laparoscopically assisted vaginal hysterectomy. Results: Operative time for vaginal hysterectomy was significantly longer for women in group 1 than for women in group 2 (66.6 ± 26.2 minutes vs 53.0 ± 25.5 minutes, P = .008). There was a linear relationship between uterine weight and operative time: Operative time = 47.156 + 0.056 × Uterine weight (r = 0.20, F = 7.66, degrees of freedom 1, 188, P = .006). Vaginal morcellation of the uterus was needed in 80.0% of the women in group 1 and in 10.0% of the women in group 2 (P < .001). Two women in group 1 (6.7%) and 9 women (5.6%) in group 2 had laparoscopically assisted procedures for lysis of adhesions, adnexectomy, or both, unrelated to uterine size (P = .69). There were no significant differences between the 2 groups with respect to perioperative hemoglobin concentration change or hospital stay. Finally, the rates of major surgical complications were similar in the 2 groups (3.3% in group 1 vs 4.3% in group 2, P > .99, 95% confidence interval –8.1% to 5.9%). Conclusions: Although vaginal hysterectomy requires a modest increase in operative time, it is as safe and effective for the woman with a moderately enlarged uterus as for the woman with a uterus of normal size. Vaginal uterine morcellation is the key to a successful operation and obviates the need for either abdominal or laparoscopically assisted hysterectomy solely to deal with moderate uterine enlargement. (Am J Obstet Gynecol 1999;180:1337-44.)     

Comparative study of vaginal,laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study

BACKGROUND: The purpose of this study was to compare peri-operative morbidity, preoperative sonographic estimation of uterine weight and postoperative outcomes of women with uterine fibroids larger than 6 cm in diameter or uteri estimated to weigh at least 450 g, undergoing either vaginal, laparoscopically assisted vaginal or abdominal hysterectomies. METHOD: Ninety patients who met the criteria of uterine fibroids larger than 6 cm by ultrasonographic examination were included in our prospective study. Patients were randomized into laparoscopic-assisted vaginal hysterectomy (30 patients), vaginal hysterectomy (30 patients) and abdominal hysterectomy (30 patients) groups. RESULTS: The laparoscopically assisted vaginal hysterectomy group had significantly longer operative times than the abdominal and vaginal hysterectomy groups (109 +/- 22 min, 98 +/- 16 min, and 74 +/- 22 min, respectively, p < 0.001). Blood loss for vaginal hysterectomy was significantly lower than for either abdominal or laparoscopically assisted vaginal hysterectomies (215 +/- 134 ml, 293 +/- 182 ml, and 343 +/- 218 ml, respectively, p = 0.04). Vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy groups had shorter hospital stays, lower postoperative pain scores, more rapid bowel recovery and lower postoperative antibiotic use than the abdominal hysterectomy group. Uterine weight in the abdominal hysterectomy group was significantly heavier than in the vaginal and laparoscopically assisted vaginal hysterectomy groups (1020 +/- 383 g, 835 +/- 330 g, and 748 +/- 255 g, respectively, p = 0.02). We estimated that when a myoma measured between 8 and 10 cm, the uterus weighed approximately 450 g, and the sensitivity of this prediction was 57.5%. For a myoma larger than 13 cm, the estimated uterine weight was more than 900 g and the sensitivity of this prediction was 71%. CONCLUSION: The study shows vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy can be performed in women with uterine weight of at least 450 g. Preoperative ultrasonographic examination can provide the surgeon with valuable information on the size of the fibroid and the estimated weight of the enlarged uterus before implementing a suitable surgical method.     

Laparoscopically-assisted vaginal hysterectomy for fibroid uteri weighing at least 500 grammes

We retrospectively reviewed the medical records of 13 women who underwent laparoscopically-assisted vaginal hysterectomy (LAVH) where the uterus weighed 500 g or more. LAVH was successfully performed in 10 of these 13 women for whom the mean uterine weight was 619 g, mean operating time 99 minutes, and mean postoperative hospital stay 3.7 days. One of the 3 women who underwent abdominal hysterectomy required blood transfusion for intraoperative bleeding. There was no febrile or other operative morbidity associated with any patient. As up to 75% of hysterectomies are performed abdominally, LAVH may replace many abdominal hysterectomies for large fibroid uteri when vaginal hysterectomy is not feasible.     

Hysterectomy for benign uterine pathology among women without previous vaginal delivery

OBJECTIVE: To evaluate the feasibility and the complication rate of vaginal hysterectomy in benign uterine pathology (except for uterine prolapse) among patients without previous vaginal delivery. METHODS: A review of the medical records in patients without previous vaginal delivery who underwent hysterectomies between January 1995 and June 2004 was carried out. Patients were divided into two different groups: group 1 included patients with first-intention abdominal hysterectomy; group 2 included patients with vaginal approach further stratified into 2a without and 2b with laparoscopic assistance. RESULTS: Three hundred patients without previous vaginal delivery underwent hysterectomy during this period. Vaginal hysterectomy was planned in 75.7% of cases. Success rate for planned vaginal hysterectomies was 92.1%. The mean weight of uteri extracted by vaginal and abdominal approaches were 326 g and 1,047 g, respectively (P<.001). The mean operative time was significantly longer in the laparoscopic-assisted approach (160 minutes) than in the abdominal approach (120 minutes), and significantly shorter in exclusively vaginal (75 minutes) than in other procedures (P<.001). The use of the laparoscopic assistance in hysterectomy decreased significantly over the period of the study (P<.001). The mean duration of hospital stay was significantly shorter in group 2 than in group 1 (3.8 days compared with 6.2 days, P<.001), but no differences were noted between subgroups 2a and 2b. CONCLUSION: Vaginal hysterectomy should not be contraindicated in patients lacking previous vaginal delivery. In these particular patients, most of the procedures can be performed by vaginal approach, with the benefit of limiting the costs and the duration of hospital stay.     

Vaginal hysterectomy in women with history of previous cesarean delivery

Objective: This study aimed to compare surgical outcomes with vaginal hysterectomy between women who have had ≥1 cesarean delivery and those who have not had a cesarean delivery. A secondary objective was to analyze the effect of previous vaginal birth on the complication rate of vaginal hysterectomy. Study Design: A retrospective analysis was performed on 221 women undergoing vaginal hysterectomy. Women were separated into those who had a history of previous cesarean deliveries (N = 35) and those who did not (N = 186). The groups were analyzed for the indications for surgery, perioperative hemoglobin loss, operative time, length of hospitalization, and complications. Trends in the complication rate for women in the previous cesarean group were also studied from the perspectives of numbers of previous cesarean deliveries and of vaginal delivery history. The 95% confidence intervals for the difference between proportions as well as P values for probability tests were calculated. P < .05 was considered significant. Results: Previous cesarean delivery experience did not affect hemoglobin change, hospital stay, or operative time among women undergoing vaginal hysterectomy. A total of 11.3% of women in the previous cesarean group had complications, versus 4.3% for the noncesarean group (P = .10, 95% confidence interval –3.8% to 18.0%). Complications did not increase with increasing number of previous cesarean deliveries (U = 1020.5, P = .28). Also, a trend toward fewer complications among patients with a history of cesarean delivery who had also had a vaginal delivery was demonstrated (U = 836, P = .05). Overall, women who were undergoing vaginal hysterectomy who had a history of ≥1 previous vaginal delivery had a complication rate of 3.2%, versus 17.6% for women who had not had a previous vaginal birth (P = .004, 95% confidence interval –27.5% to –1.3%). Conclusions: In this study women who had a history of previous cesarean delivery were not at higher risk for greater hemoglobin loss, longer hospital stay, more prolonged operative time, or significantly more perioperative complications when undergoing vaginal hysterectomy than were those women who had no history of previous cesarean delivery. Likewise, increasing the number of previous cesarean deliveries did not have an adverse impact on the complication rate. Previous vaginal delivery lowered the risk of complications from vaginal hysterectomy. (Am J Obstet Gynecol 1998;179:1473-8.)     

Outpatient vaginal hysterectomy is safe for patients and reduces institutional cost

OBJECTIVE: To evaluate a management protocol based on scientific evidence in the care of patients undergoing vaginal hysterectomy. STUDY DESIGN: (Canadian Task Force classification II-2). SETTING: 110-bed community hospital. PATIENTS: Women with vaginal hysterectomy between 2000 and 2003. INTERVENTION: Data were collected on all vaginal hysterectomies performed by a single surgeon over a 4-year period. Demographics, surgical indications, procedural parameters, length of stay, and postoperative complications were evaluated. Hospital costs for all vaginal hysterectomies performed over a 2-year period at the same hospital also were examined. An analysis of the literature was performed to develop a protocol for optimizing patients' surgical experience. All patients were managed using the protocol. These patients were compared with a cohort at the same institution. MEASUREMENTS AND MAIN RESULTS: Four hundred twelve vaginal hysterectomies were performed by the lead author during the 4-year time period. Three hundred eighty-four patients (93%) were discharged within 12 hours of admission. There were no readmissions for bleeding, pain management, urinary retention, or nausea and vomiting. Four hundred nineteen vaginal hysterectomies were performed by 10 surgeons from 2002 through 2003 at the same institution, including 219 by the lead author. The average direct cost for outpatient vaginal hysterectomy was 21.3% lower than for inpatient vaginal hysterectomy. CONCLUSION: Incorporating a protocol based on scientific evidence into the management of surgical patients facilitated safe outpatient vaginal hysterectomy in a majority of patients. This optimized management may save up to 25% of the cost for these procedures.     

Recovery from vaginal hysterectomy compared with laparoscopy-assisted vaginal hysterectomy: a prospective, randomized, multicenter study

OBJECTIVE: To evaluate short-term recovery of vaginal hysterectomy with those of laparoscopic assisted vaginal hysterectomy performed in a prospective, randomized multicentric study. STUDY DESIGN: Eighty patients referred for hysterectomy for benign pathology were randomized to either vaginal hysterectomy (40 patients) or laparoscopic assisted vaginal hysterectomy (40 patients). Inclusion criteria were uterine size larger than 280 g and one or more of the following: previous pelvic surgery, history of pelvic inflammatory disease, moderate or severe endometriosis, concomitant adnexal masses, and indication for adnexectomy. No upper limit of uterine size was set. All the laparoscopic and the vaginal hysterectomies were done under endotracheal general anesthesia. RESULTS: There was no statistically significant difference in terms of patient's age, parity, postmenopausal state, indication for surgery and mean uterine weight between the 2 groups. Laparoconversion was performed in three women in the laparoscopic group. Operative time was significantly shorter in the vaginal versus the laparoscopic groups 108+/-35 and 160+/-50 respectively (p<0.001). The use of paracetamol, non steroidal anti-inflammatory drugs, and opioid during hospitalization were similar in the 2 groups. There was no difference in the 1st day hemoglobin level drop, time of passing gas and stool, or hospital stay between the 2 groups. CONCLUSION: In contrast with earlier reports, there was no difference in short-term recovery between patients undergoing vaginal or laparoscopic hysterectomy. No advantage was found performing laparoscopic assisted vaginal hysterectomy in comparison with the standard vaginal hysterectomy.     

The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital

Objective: Our purpose was to evaluate the medical and economic impact of operative laparoscopy on the surgical approach to hysterectomy for benign disease in a large, metropolitan, not-for-profit hospital.Study design: Retrospective analyses were performed on 2563 hysterectomies (without vaginal or bladder repair) for benign disease, performed and stapling devices were not used at any time during the study period. Electrosurgery and sutures were used for hemostasis. Parameters analyzed included surgical approach (total abdominal hysterectomy, vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and failied laparoscopically assisted vaginal hysterectomy), operative time, postoperative diagnosis, operative blood loss, length of stay, complications, uterine weight, and hospital changes. Changes in each of these parameters were analyzed and compared in 6-month increments.Results: During the study period the percent of hysterectomies performed abdominally declined from 65% to 36%. Laparoscopically assisted vaginal hysterectomy increased from 12% to 45%, and vaginal abdominal hysterectomy, 102 minutes (=2.3 minutes) for laparoscopically assisted vaginal hysterectomy, and 63 minutes (±2 minutes) for vaginal hysterectomy. Hospital stay was 68 hours (±1.5 hours) for total abdominal hysterectomy, 44 hours (±1.2 hours) for laparoscopically assited vaginal hysterectomy, and 43 hours (±4.1 hours) for vaginal hysterectomy. The average hospital charge was $6552 (±$108) for total abdominal hysterectomy, $6431 (±$100) for laparoscopically assisted vaginal hysterectomy, and $5869 (±$116) for vaginal hysterectomy.Conclusions: Contrary to previously published studies, our study demonstrates (1) laparoscopically assisted vaginal hysterectomy is a cost-effective procedure when performed with reusable instruments, (2) laparoscopically assisted vaginal hysterectomy is a safe procedure, even when performed by a variety of gynecologists with different skill levels, and (3) the number of hysterectomies performed abdominally was decreased by 29% without incurring more complications or reducing the number of vaginal cases.     

Vaginal hysterectomy for the large uterus

Objective To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size.
Design A prospective observational study.
Setting The Royal Free Hospital, London.
Participants Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size.
Interventions Vaginal hysterectomy with or without bilateral salpingo-oophorectomy or oophorectomy.
Main outcome measures Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra-and post-operative complications, duration of hospitalisation.
Results The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (   n = 6  ) and superficial vaginal grazes (   n = 5  ). One of the women required a blood transfusion. The mean post-operative hospital stay was 3.7 days (range 2 to 9 days).
Conclusion Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.     

Peripartum hysterectomy: a review of cesarean and postpartum hysterectomy

A retrospective review of 117 women who underwent peripartum hysterectomy at Duke University Medical Center during the past 21 years was conducted. Seventy-three cesarean hysterectomies were performed electively; 44 cesarean or postpartum hysterectomies were performed as emergencies. Statistically significant differences were noted between these groups in surgical technique, operative time, estimated blood loss, intraoperative hypotension, and intraoperative and total blood replacement. Additional significant differences were noted in postoperative febrile morbidity, use of therapeutic antibiotics, incidence of thromboembolic phenomena, and length of postoperative hospital stay. Separate analysis of elective cesarean hysterectomy patients revealed statistically significant decreases in operative time, estimated blood loss, intraoperative and total blood replacement, and postoperative hospital stay in the group having an experienced surgeon when compared with the group with less experienced surgeons.     

Ten-year review of hysterectomy morbidity and mortality: can we change direction?

The medical records of all women who underwent hysterectomy for benign disease performed between 1986 and 1995 were reviewed to ascertain the incidence of morbidity and mortality of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy at a university teaching hospital. A total of 1940 hysterectomies were performed during this period; 74% of hysterectomies were performed abdominally, 24% vaginally and 2% were laparoscopically assisted. In 80% of the patients uterine leiomyomas, adenomyosis, dysfunctional uterine bleeding or uterine prolapse were the indications for hysterectomy The overall complication rate was 44% for abdominal hysterectomy (AH) and 27.3% for vaginal hysterectomy (VH). An unintended major surgical procedure was required in 3% and 1% of women undergoing AH and VH respectively The rate of return to the operating room for haemostasis was 0.6% for AH and 0.2% for VH. The AH group was four times more likely than the VH group to require surgical intervention (36% versus 9%) at readmission. Vaginal hysterectomy was associated with a lower febrile morbidity and minor complication rate. Prophylactic antibiotics reduced the febrile morbidity for VH and AH by 50% (Student's t-test, p = 0.02) and 40% (Student's t-test, p < 0.001) respectively The overall mortality rate was 1.5 per 1000.     

Randomized,prospective, double-blind comparison of abdominal and vaginal hysterectomy in women without uterovaginal prolapse

BACKGROUND: To determine under controlled conditions whether there are significant differences in the duration of hospitalization and recovery between abdominal and vaginal hysterectomy for indications other than uterovaginal prolapse. METHOD: In a two-center prospective, double-blind randomized trial, 36 women with dysfunctional uterine bleeding, uterine fibroids or pelvic pain scheduled for hysterectomy were randomized to abdominal or vaginal hysterectomy. The primary outcome measure was the duration of hospital stay. Secondary outcome measures included analgesic requirements and return to normal health and function. RESULTS: There were no significant differences in peri-operative patient or surgical characteristics. Vaginal hysterectomy was associated with a reduction in hospital stay compared to abdominal hysterectomy (median stay 3 days vs. 5 days, p = 0.01). In addition, patients undergoing vaginal hysterectomy had reduced analgesic requirements (mean 75.4 mg vs. 131.4 mg morphine equivalent, p = 0.002), shorter need for intravenous hydration (mean 25.3 h vs. 32.7 h, p = 0.05), and faster return of bowel action (median 3 days vs. 4 days, p = 0.002). They also returned to normal domestic activities (mean 4.6 weeks vs. 8.5 weeks, p = 0.01) and work (mean 7.0 weeks vs. 13.9 weeks, p = 0.005), and completed their recovery (mean 7.9 weeks vs. 16.9 weeks, p = 0.008) more quickly. CONCLUSIONS: Vaginal hysterectomy was associated with significant benefits in terms of reduced hospital stay and improved patient recovery. Vaginal hysterectomy should be the route of choice not only for women with genital tract prolapse but also those without.     

Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial

OBJECTIVE: The purpose of this study was to compare advantages, disadvantages, and outcomes in patients who undergo vaginal or abdominal hysterectomy for enlarged symptomatic uteri. STUDY DESIGN: In a prospective, randomized study, 60 vaginal hysterectomies (study group) were compared with 59 abdominal hysterectomies (control group); all of the hysterectomies were performed for symptomatic uterine fibroids from January 1997 through December 2000. We excluded from the study the other common causes of hysterectomy such as prolapse, bleeding, adenomyosis, and endometrial or cervical carcinoma. In both groups, uterine weights ranged from 200 g to 1300 g. For enlarged uteri, vaginal hysterectomies were performed with the use of volume reduction techniques: Intramyometrial coring, corporal bisection, and morcellation. The evaluated parameters included patient age, weight, parity, uterine weight, operative time, blood loss, demand for analgesics, eventual surgical complications, length of admission, and hospital charges. The Mann-Whitney U test and chi(2) tests were applied for statistical analysis. Probability values of <.05 were considered statistically significant. RESULTS: There were no major differences in patient age, weight, parity, and uterine weight between the two groups. Operative time was significantly lower for the vaginal route as compared with the abdominal route (86 minutes vs 102 minutes, P <.001). No intraoperative complications were noted both in the study and control groups or the control group. Surgical bleeding (expressed by hemoglobin loss) was not significantly different between the two groups. In the postoperative period, we found a higher incidence of fever (30.5% vs 16.6%, P <.05) and demand for analgesics (86% vs 66%, P <.05) in the abdominal group as compared with the vaginal group. Significant advantages of vaginal hysterectomy were a reduction in the hospital stay (3 days vs 4 days, P <.001) and cost. CONCLUSION: These results should lead to the choice of vaginal hysterectomy as a valid alternative to the abdominal hysterectomy, even for enlarged uteri.     

Assessing the impact of introducing laparoscopically assisted vaginal hysterectomy into a community-based gynecology practice

This study was undertaken to determine the effects of introducing laparoscopically assisted vaginal hysterectomy (LAVH) into a community-based gynecology practice on the route of hysterectomy, operating time, patient costs, length of hospitalization, and morbidity, including complications and blood loss. All patients in the author's practice who had hysterectomies during the 10 months before completion of an advanced operative laparoscopy course were compared with the patients having a hysterectomy in the 10 months after the course. The route of hysterectomy, surgery time, length of hospital stay, preoperative and postoperative hemoglobin, uterine weight, diagnoses, and historical clinical data were compared between the two groups using a level of significance (alpha = 0.01) to assess statistical relevance. The rate of vaginal hysterectomy was remarkably higher in the AFTER group (53.2%, n = 62) vs the BEFORE group (27.7%, n = 65). The AFTER group had a significantly shorter hospital stay (3.4 days +/- 1.22 vs 4 days +/- 1.26, p < or = 0.01) but a much longer surgery time (115.9 min +/- 38.98 vs 80.1 min +/- 27.95, p < or = 0.01). There was no real difference in complication rates or fall in hemoglobin between the two groups. When LAVH was compared with TAH, the LAVH patients tended to be younger (37.4 +/- 8.66 vs 46.2 +/- 16.5 years) and to have a shorter hospital stay (3.1 +/- 0.99 vs 4.1 +/- 1.27 days), a longer surgery time (114.9 +/- 37.45 vs 85.3 +/- 33.74 min), and a bigger hospital bill ($6245 +/- 380 vs $5140 +/- 410) than patients with TAH.(ABSTRACT TRUNCATED AT 250 WORDS)     

Laparoscopic subtotal hysterectomy versus laparoscopic total hysterectomy: a decade of experience

At present, there are only few data on the surgical outcomes of laparoscopic hysterectomy (LH). Up till now, it has been unclear whether there is a difference in number of complications among the subcategories of laparoscopic total hysterectomy and laparoscopic subtotal hysterectomy (LSH). Therefore, we have performed a retrospective analysis to evaluate the peri- and postoperative outcomes in women undergoing LSH versus LH. This multi-centre retrospective cohort study (Canadian Task Force classification II-2) was conducted in multi-centres (two teaching hospitals and one university medical centre) in the Netherlands, all experienced in minimally invasive gynaecology. In a multi-centre retrospective cohort study we compared the long-term outcomes of laparoscopic subtotal hysterectomy and laparoscopic total hysterectomy (including laparoscopic assisted vaginal hysterectomy, laparoscopic hysterectomy and total laparoscopic hysterectomy). All laparoscopic hysterectomies from the last 10 years (January 1998 till December 2007) were included. Patient characteristics, intra- and postoperative complications, operating time and duration of hospital stay were recorded. The minimum follow-up was 6 months. A total of 390 cases of laparoscopic hysterectomies were included in the analysis: 192 laparoscopic subtotal hysterectomies and 198 laparoscopic total hysterectomies. Patient characteristics such as age and parity were equal in the groups. The overall number of short-term and long-term complications was comparable in both groups: 17% and 15%. Short-term complications (bleeding, fever) were 3% in the LSH group and 12% in the LH group. Long-term complications were (tubal prolapse and cervical stump reoperations) 15% in the LSH group and 3% in the LH group. Laparoscopic subtotal hysterectomy as compared with the different types of laparoscopic total hysterectomy is associated with more long-term postoperative complications, whereas laparoscopic total hysterectomy is associated with more short-term complications.