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.     

Morbidity of vaginal hysterectomy for benign tumors as a function of uterine weight

OBJECTIVE: To evaluate the relationship between uterine weight and morbidity in women undergoing vaginal hysterectomy. STUDY DESIGN: A prospective study of vaginal hysterectomy was carried out in women with benign uterine tumors. The only exclusion criteria were a suspected adnexal mass, a very narrow vagina and an immobile uterus. The women were stratified into 3 groups according to uterine weight. The groups were compared as regards indications, operative time, complication rates, analgesia requirements and postoperative recovery. RESULTS: A total of 214 women underwent vaginal hysterectomy: group 1, n = 114, uteri < 180 g; group 2, n = 73, uteri 180-500 g; group 3, n = 27, uteri > 500 g (maximum 1,350 g). The groups differed with respect to mean age (P = .003) and menopausal status (P = .002) but not gravidity, parity, previous pelvic surgery or preoperative hemoglobin levels. Concerning the indications for hysterectomy, only the incidence of pelvic compression differed between the groups (P = .04). There was no difference in the frequency of concomitant surgical procedures (e.g., adnexectomy) between the groups. Morcellation rate was 30% in group 1, 73% in group 2 and 100% in group 3. The overall complication rate was not significantly different between the groups: 20.1%, 15.0% and 22.2%, respectively. The only major complication was an injury to the in-fundibulopelvic ligament in a group 1 patient. Operative time increased significantly with uterine weight (82 +/- 35.4, 91.8 +/- 35.4 and 94.8 +/- 36.5 minutes, respectively; P = .01). There were no significant differences between the groups as regards perioperative hemoglobin loss, analgesia requirements, time to flatus and stool return or length of hospital stay. CONCLUSION: Vaginal hysterectomy can be performed successfully even in the case of greatly enlarged uteri; nulliparity and a history of pelvic surgery are not absolute contraindications.     

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.)     

Laparoscopically assisted vaginal hysterectomy for large uterus: a comparative study

OBJECTIVE: To examine the safety and feasibility of laparoscopically assisted vaginal hysterectomy (LAVH) for uteri weighing 500 g or more as compared to uteri weighing less than 500 g in the management of benign gynecological diseases. METHOD: In this prospective comparative study, 189 women with different benign gynecological diseases were scheduled for laparoscopically assisted vaginal hysterectomy. They were divided into two groups, with uterine weight greater than 500 g and uterine weight less than 500 g. Outcome measures for both the groups were studied comparatively in terms of length of operative time, amount of blood loss, requirement of blood transfusion and length of hospital stay. RESULTS: Length of operation and amount blood loss were significantly greater in the uteri >o r = 500 g group than in the <500 g at 91.1 +/- 28.7 min versus 77.4 +/- 26.6 min (P < 0.01), and 570.5 +/- 503.6 ml versus 262.5 +/- 270.0 ml (P < 0.001), respectively. However, there was no difference in length of hospital stay and overall incidence of operative complications between the two groups. None of the women had any major complications though 17 minor complications were noted. There was no incidence of switching to abdominal laparatomy during the operation except for one patient who required "minilaparotomy" for removal of large surgical specimen (2400 g). Extreme intra-operative hemorrhage of more than 1000 ml occurred in five patients, however, they made full recovery after blood transfusion. Rate of blood transfusion was significantly lower in the uteri <500 g group (4.8% versus 34.9%, (P < 0.001). CONCLUSION: This study demonstrates that despite the increased operating time and blood loss, LAVH can be safely performed for large uterus. However, surgeons need to be aware of the high risk of blood transfusion in these patients.     

Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids

Objective To compare laparoscopically assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH) in patients with uterine fibroids.
Design A prospective randomised study.
Setting The San Paolo Hospital, Milan.
Population Sixty-two patients, who were not suitable for a vaginal hysterectomy, requiring treatment for uterine fibroids.
Methods Randomisation between LAVH and TAH. Comparison of outcomes on the whole series, patients with uteri ≤ 500 g (Group 1) and patients with uteri > 500 g (Group 2).
Main outcome measures To establish operating time, blood loss, complications, febrile morbidity, analgesics administration and hospital stay for both treatment approaches.
Results Median uterine weight was 400 g in both LAVH and TAH group. Median operating time was longer for LAVH (135 min compared with 120 min for TAH;   P = 0.001  ), but patients undergoing LAVH had less analgesics administration (23% compared with 77%,   P < 0.001  ) and a shorter median hospital stay (3.8 compared with 5.8 days;   P < 0.001  ). LAVH, when compared with TAH in the two weight subgroups, required a significantly longer operating time only in Group 2, significantly reduced analgesics administration only in Group 1, and significantly reduced hospital stay in both groups. Conversions of LAVH to laparotomy were significantly more frequent in Group 2 (3/11) than in Group 1 (0/20) (   P = 0.04  ).
Conclusions Compared with TAH, LAVH has advantages in removing uteri weighing ≤ 500 g, with comparable operating time, less post-operative pain and shorter recovery. Among uteri weighing > 500 g LAVH showed a shorter recovery, but longer operating time than TAH and a 27% rate of conversion to laparotomy.     

Hysterectomy for the massive leiomyomatous uterus

OBJECTIVE: To determine if the complication rate of abdominal hysterectomy is increased in women with greatly enlarged myomatous uteri. METHODS: Three groups of women undergoing abdominal hysterectomy were analyzed according to uterine size: group 1, 208 women with uteri less than 500 g; group 2, 63 women with uterine weights of 500-999 g; and group 3, 47 women with leiomyomata whose uteri weighed at least 1000 g. Logistic regression was used to compare the groups on the risks of having at least one major complication. Adjusted comparisons on other surgical outcomes were performed using a logistic model (for qualitative variables) or a general linear model (for quantitative variables). RESULTS: The risk of experiencing at least one perioperative complication, including blood loss over 500 mL, perioperative blood transfusion, major organ injury, therapeutic antibiotic use, and hospital readmission, increased significantly with uterine weight (P =.006). Group 3 women were at greater risk of having at least one of these complications than either group 1 or group 2 women, with adjusted odds ratios of 3.42 (95% confidence interval [CI] 1.62, 7.25) and 2.64 (95% CI 1.14, 6.13), respectively. Estimated blood loss with surgery also increased with increasing uterine weight (P <.001). Mean estimated blood losses for the study groups were 555.8 +/- 386.5 mL (group 3), 464.3 +/- 285.2 mL (group 2), and 387.6 +/- 281.4 mL (group 1) (P =.032). CONCLUSION: The complication rate from hysterectomy increases with increasing uterine weight, due mainly to an increased blood loss associated with surgery for larger uteri.     

Uterine weight as a predictor of morbidity after a benign abdominal and total laparoscopic hysterectomy

OBJECTIVE: To determine if an enlarged uterus is associated with an increased rate of intraoperative and postoperative complications and prolonged hospital length of stay (LOS) after benign total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH). STUDY DESIGN: Women who underwent TAH or TLH were stratified, according to uterine weight, into 3 groups: group 1, uterine weight < 200 g; group 2, 201-500 g; and group 3, > 500 g. Indications included uterine leiomyomas, chronic pelvic pain, prolapsed uterus, endometriosis and adenomyosis, dysfunctional uterine bleeding; all had benign final pathology. Statistical analysis compared risks of intraoperative and postoperative morbidity and prolonged hospital stay. RESULTS: Prolonged hospital stay risk increased for uterine weight > 500 g (p < or = 0.001). There was a significant association between postoperative complications and uterine size (p < or = 0.001). Mean estimated blood loss (EBL) also increased with uterine weight > 500 g (p < or = 0.001). TLH was associated with fewer postoperative complications, shorter LOS and reduced EBL (p < or = 0.001). CONCLUSION: Average LOS and risk of blood loss, blood transfusion and other postoperative complications after hysterectomy for benign disease increased with increasing uterine weight. TLH is an excellent alternative for enlarged uteri; it was strongly associated with decreased morbidity, shorter LOS, and reduced EBL and blood transfusion rate in all uterine weight groups when adjusted for other variables.     

Feasibility of Oophorectomy at the Time of Vaginal Hysterectomy in Patients with Pelvic Organ Prolapse

Study ObjectiveTo determine the feasibility of oophorectomy at the time of vaginal hysterectomy in patients with pelvic organ prolapse and to define prognostic factors and perioperative morbidity associated with the procedure.DesignA retrospective cohort study (Canadian Task Force classification II-2).SettingAn academic medical center.PatientsAll women who underwent total vaginal hysterectomy for the treatment of pelvic organ prolapse over 5 years were considered for inclusion in the study.InterventionsTotal vaginal hysterectomy and concomitant pelvic organ prolapse repair with or without oophorectomy.Measurements and Main ResultsA total of 289 women underwent total vaginal hysterectomy with pelvic organ prolapse repair. Vaginal oophorectomy was attempted in 179 patients (61.9%). The procedure was successful in 150 patients (83.8%; 95% confidence interval [CI], 77.6%–88.9%). High ovarian location was the most commonly cited reason for the inability to perform a planned unilateral/bilateral oophorectomy (n = 24, 82.7%). Attempting oophorectomy vaginally was associated with an increased duration of surgery by 7.3 minutes (p = .03), an increased change in hemoglobin by 0.2 g/dL (p = .02), and a higher rate of readmission (7.3% vs 1.8%, p = .04). Multiple logistic regression showed that increasing age (odds ratio = 1.12; 95% CI, 1.05–1.20; p <.001) and body mass index (odds ratio = 1.17; 95% CI, 1.07–1.27; p<.001) were associated with an increased risk of vaginal oophorectomy failure. On univariate analysis, race (p = .64), parity (p = .39), uterine weight (p = .91), need for uterine morcellation (p=.21), presence of endometriosis (p=.66), prior cesarean section (p=.63), prior laparoscopy (p=.37), and prior open abdominal/pelvic surgery (p = .28) did not impact the likelihood of successfully performing oophorectomy.ConclusionIn patients with pelvic organ prolapse, a planned oophorectomy at the time of vaginal hysterectomy can be successfully performed in the majority of cases. Greater age and body mass index are associated with an increased likelihood of failure.     

Abdominal hysterectomy for the enlarged myomatous uterus compared with vaginal hysterectomy with morcellation

OBJECTIVE: The purpose of this study was to compare intraoperative and postoperative complications of abdominal hysterectomy for the enlarged, myomatous uterus with vaginal hysterectomy with morcellation. STUDY DESIGN: Medical records of 139 patients who underwent vaginal hysterectomy with morcellation and 244 patients who underwent total abdominal hysterectomy for an enlarged, myomatous uterus between August 1990 and July 2001 were reviewed. Uterine weights of >982 g were excluded because this was the largest uterus removed vaginally, which left 208 evaluable cases of total abdominal hysterectomy. The perioperative and postoperative course of the two groups was compared. The Student t test was used for continuous variables, and the Fisher exact test was used for binary or categoric data. RESULTS: There were no significant differences between the two groups in surgical or anesthetic risk factors (P>.05). Operative time was similar between the groups (P>.05). Length of hospital stay was increased significantly with total abdominal hysterectomy (mean, 3.9 days vs 2.6 days; P<.001). Perioperative complications were increased with the abdominal route (10% vs 25%, P<.001). CONCLUSION: In this large series, uterine morcellation at the time of vaginal hysterectomy is safe and facilitates the removal of moderately enlarged and well-supported uteri and is associated with decreased hospital stay and perioperative morbidity rate compared with the abdominal route.     

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.     

Total laparoscopic hysterectomy for very enlarged uteri

STUDY OBJECTIVE: To evaluate short-term outcome of total laparoscopic hysterectomy (TLH) performed in women with very enlarged uteri. DESIGN: Case control study (Canadian Task Force classification II-2). SETTING: Hospital gynecologic service. PATIENTS: Thirty-four consecutive women with very enlarged uteri. INTERVENTION: Total laparoscopic hysterectomy for benign pathology. MEASUREMENTS AND MAIN RESULTS: Women with uterine enlargement (group 1) were compared with 68 women with uteri weighing 300 g or less (group 2) who underwent TLH during the same period. Matching was based on patient age +/- 2 years, surgeon (experienced senior, fellow), whether or not Burch operation was performed, and whether or not adnexectomy was performed. The groups were compared for complication rates, operating time, hospital stay, change in perioperative hemoglobin concentration, and vaginal and laparoscopic uterine morcellation. They did not differ statistically significantly in terms of indications for surgery, parity, postmenopausal status, and preoperative hemoglobin levels. No difference was seen in complication rates between groups. Operating time was significantly shorter (p <0.001) in women with smaller uteri than in those with very enlarged uteri, 108 +/- 35 and 156 +/- 50 minutes, respectively. The groups did not differ significantly in day 1 hemoglobin level drop, analgesia requirement (oral, intravenous opioid), time to passing gas and stool, or hospital stay. No conversion to laparotomy was required in either group. CONCLUSION: A very enlarged uterus should not be considered a contraindication for TLH. However, it may be necessary to undertake certain surgical steps to ensure optimal exposure of the operative field and more effective and safer excision of the uterine vascular pedicle.     

Laparoscopic-assisted vaginal hysterectomy with uterine artery ligation through retrograde umbilical ligament tracking

STUDY OBJECTIVE: To evaluate the clinical outcomes of uterine artery ligation through retrograde tracking of the umbilical ligament (RUL) in laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective study (Canadian Task Force classification II-3). SETTING: University-affiliated hospital. PATIENTS: Two hundred twenty-five women with myomas or adenomyosis. INTERVENTION: Laparoscopic-assisted vaginal hysterectomy with uterine artery identification and ligation through RUL. MEASUREMENTS AND MAIN RESULTS: The median age of the patients was 46 years, and the median weight of the extirpated uteri was 340 g, with 26.2% of uteri weighing more than 500 g. The median operation time was 135 minutes, and the median blood loss was 50 mL. The median intramuscular meperidine requirements were 1 ampoule (50 mg), and the median hospital stay was 3 days. It took approximately 10 minutes from identification of the umbilical ligament to ligation of the uterine artery. Uterine weight of 500 g or more required a significantly longer operation time compared with uteri weighing less than 500 g (164 min vs 127 min median, p <.001), and there was more blood loss (100 mL vs 50 mL median, p <.001). There were no differences in the median intramuscular meperidine requirements or hospital stay between the two groups. No blood transfusion was needed in either group, even in patients with a uterine weight of more than 1000 g. By regression analysis, uterine weight was significantly related to blood loss and operation time. A linear relationship was found among uterine weight, operation time, and blood loss: Uterine weight = 87.589 + 1.881 x operation time + 0.48 x blood loss (R = 0.531, F = 35.694, degrees of freedom 184, p <.001). No complications related to RUL were observed, although two bladder injuries related to severe pelvic adhesion with endometriosis and previous cesarean section occurred. CONCLUSION: Minimal blood loss and a low complication rate were noted in LAVH by uterine artery ligation through RUL. This technique should be a valid approach, especially in patients in whom minimal blood loss must be achieved.     

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     

A prospective randomized comparison of vaginal hysterectomy,laparoscopically assisted vaginal hysterectomy,and total laparoscopic hysterectomy in women with benign uterine disease

Objectives

To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).

Study design

A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.

Results

Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.

Conclusions

Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.     

Laparoscopic Hysterectomy in Case of Uteri Weighing ≥1 Kilogram: A Series of 71 Cases and Review of the Literature

Study ObjectiveTo present our experience with laparoscopic hysterectomy (LH) for uteri weighing 1 kilogram or more and to provide a systematic review of the available English literature.DesignRetrospective analysis and review of the literature (Canadian Task Force Classification II-2).SettingDepartment of Obstetrics and Gynecology, University of Insubria, Varese, Italy.PatientsAll women in whom LH was attempted at the Department of Obstetrics and Gynecology, University of Insubria for uteri weighing ≥1 kg were included in the present study. Demographic characteristics and perioperative details of patients were prospectively recorded in our institutional surgical database. We also performed a systematic review of the English literature to identify studies including at least 1 case of LH for uteri weighing ≥1 kg.InterventionsHysterectomy for uteri ≥1 kg was performed through a total laparoscopic approach with vaginal morcellation of the uterus in the majority of patients and transvaginal closure of the vaginal vault in all cases.Measurements and Main ResultsLH was attempted in a total of 71 women. The median uterine weight was 1120 g (1000–2860 g). Three (4.2%) conversions to open surgery were needed. The median operative time and blood loss were 120 minutes (55–360 minutes) and 200 mL (10–1000 mL), respectively. No intraoperative and 2 (2.8%) postoperative complications occurred. Our review identified 6 studies reporting details of LH for uteri weighing ≥1 kg for a total of 62 patients; conversion to open surgery was necessary in 6 (9.7%) patients, and an additional 13 (21%) received a minilaparotomic incision to extract the uterus. The overall complication rate reported in the literature was 11.4%.ConclusionLH represents a possibility even in cases of uteri weighing ≥1 kg. In a dedicated setting with high endoscopic experience, conversion and complication rates appear acceptable.     

Medical debulking with gonadotrophin-releasing hormone agonists to facilitate vaginal hysterectomy

Although the superiority of vaginal compared to abdominal hysterectomy is well established, most gynaecologists still prefer the abdominal route for removal of benign large uteri >14 weeks. Gonadotrophin-releasing hormone agonists such as goserelin can reduce uterine bulk by up to 60% and was initially used to convert a midline to Pfannenstiel incision in abdominal hysterectomy. The conversion of an abdominal to a potential vaginal hysterectomy by uterine size reduction would prove advantageous, and the authors present data from a case control study of 12 women with uteri >14 weeks who successfully underwent vaginal hysterectomy following preoperative treatment with goserelin. Women scheduled for hysterectomy for menorrhagia with non-prolapsing clinical uterine size of >14 weeks were offered an attempt at vaginal hysterectomy after pre-treatment with goserelin. A group of women with comparable uterine size who underwent abdominal hysterectomy for similar indication served as control. Pre- and postoperative data such as haemoglobin, myoma size, uterine weight, duration of procedure and complications were collected prospectively. Both groups had comparable preoperative haemoglobin, subjective preoperative uterine bulk (median 16 weeks) and body mass index. The vaginal hysterectomy group received a median of two goserelin injections prior to surgery, and the uterine weight at histology was similar in both groups (median 580 vs 609 g, p < 0.05). The duration of surgery was twice as long in vaginal compared to abdominal hysterectomy (153.7 vs 85 min, p < 0.05), but analgesia use and the length of inpatient stay were lower in the study group (2.62 vs 3.5 days, p < 0.05). In women with >14 week-size uteri, treatment with gonadotrophin agonists reduces uterine size sufficiently to allow safe vaginal hysterectomy. Although duration of surgery was longer, women who underwent vaginal hysterectomy required less analgesia and had shorter inpatient stay.     

Laparoscopic-assisted vaginal hysterectomy with in situ morcellation for large uteri

STUDY OBJECTIVE: To estimate whether laparoscopic in situ morcellation (LISM) can facilitate laparoscopic-assisted vaginal hysterectomy (LAVH) for large uteri. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: In all, 147 women with myoma or adenomyosis weighing more than 500 g from January 2004 through December 2007 were enrolled. The patients were divided into 4 subgroups: patients with uteri weighing 500 to 749 g who had traditional LAVH without LISM (group 1A, n = 69) or with LISM (group 1B, n = 16); and patients with uteri weighing 750 g or more who were treated by traditional LAVH without LISM (group 2A, n = 38) or with LISM (group 2B, n = 24). INTERVENTIONS: Laparoscopic-assisted vaginal hysterectomy with or without LISM. MEASUREMENT AND MAIN RESULTS: No significant differences existed in age, body mass index, preoperative diagnoses, complications, or duration of hospital stay among groups. The mean uterine weights were 608 +/- 75, 597 +/- 66, 989 +/- 179, and 935 +/- 226 g for groups 1A, 1B, 2A, and 2B, respectively. The operative time (120 +/- 16 vs 157 +/- 36 minutes, p <.001; 140 +/- 19 vs 224 +/- 57 minutes, p <.001) were significantly shorter in patients with LISM than without in both groups 1 and 2. The estimated blood loss was highest in group 2A. Six (16%) patients lost more than 500 mL of blood and 3 (8%) of them needed blood transfusions. Conversion to laparotomy occurred in 1 (2.6%) of 38 patients in group 2A. No repeated surgery or surgical mortality occurred. CONCLUSION: Laparoscopic-assisted vaginal hysterectomy with LISM was an efficient and safe procedure for removal of large uteri during LAVH.     

Does medical debulking with gonadotrophin-releasing hormone agonist facilitate vaginal hysterectomy with a moderate enlarged uterus? A randomized control study

Background

Vaginal hysterectomy is considered the method of choice for removal of the uterus but most gynecologists still prefer the abdominal route for removal of benign uteri >14 weeks in size. Conversion of an abdominal to a potential vaginal hysterectomy by uterine size reduction would be advantageous. Gonadotrophin-releasing hormone (GnRH) agonists can reduce uterine bulk by up to 50%.

Objective

To evaluate the efficacy of the preoperative administration of a GnRH agonist for women with enlarged non-prolapsing uteri in order to facilitate vaginal hysterectomy, in comparison with patients with enlarged uteri who underwent direct total abdominal hysterectomy (TAH) for the same indication (menorrhagia).

Study design

Randomized controlled study. Women scheduled for hysterectomy for menorrhagia with a non-prolapsing uterus of ≥14 weeks size (by clinical and sonographic assessments) were offered a trial of vaginal hysterectomy after pre-treatment with a GnRH agonist (goserelin) for 3 months (study group = Group 1 = 40). A group of women with uteri of comparable size who underwent abdominal hysterectomy for similar indications served as controls (Group 2 = 40). Pre- and post-operative data such as hemoglobin, myoma size, uterine weight, duration of procedure and complications, pain score and length of hospital stay were collected prospectively.

Results

The weight of the uterine specimen was significantly lower in Group 1 (511.7 ± 217 g) compared to Group 2 (736.8 ± 212 g); P < 0.001. The mean objective decrease in clinical uterine bulk preoperatively in Group 1 was 20.1%. The duration of surgery was nearly 1.5 times as long in vaginal (119.6 ± 41.7 min) compared to abdominal hysterectomy (81.1 ± 34.1 min), P < 0.001, but analgesia use and the length of inpatient stay were significantly lower in Group 1 (2.6 ± 1.3 days) compared to Group 2 (4.12 ± 1.7 days), P < 0.001. There was no significant difference between the two groups as regards the rate of occurrence of surgical complications.

Conclusions

In women with ≥14 week size uteri, treatment with a GnRH agonist reduces uterine size sufficiently to allow safe vaginal hysterectomy. Although duration of surgery was longer, women who underwent vaginal hysterectomy required less analgesia and had a shorter inpatient stay.     

中等大良性病变子宫经阴全子宫切除术的探讨

目的：探讨中等大、良性病变的非脱垂子宫经阴道行全子宫切除术的可行性。方法：87例施行此术式,其中子宫中等大（重200～750g）60例作为研究组,小子宫（＜200g）27例作为对照组,部分病例采用子宫分碎术。对两组因手术期情况进行分析。结果：研究组59倒成功地经阴道切除子宫,其中21例（35％）采用子宫分碎术,1例转经腹手术,转经腹手术率为1．7％,对照组则全部经阴道完整切除。研究组和对照组的子宫重量分别为280．18±100．40g、146．48±35．19g,差异有高度显著性（P＜0．001）;研究组的平均手术时间为83．93±26．26min,长于对照组的55．22±20．55min,差异有高度显著性（P＜0．001）;术中平均出血量为164．92±89．83ml,多于对照组的135．56±111．57ml,但差异无显著性（P＞0．05）;术后病率分别为3．33％与3．70％,差异无显著性（P＞0．05）;两组患者均无膀胱、直肠损伤,无阴道残端炎症。结论：对具备经阴道手术经验的术者,中等大、良性病变的子宫经阴道切除是安全可行的。部分病例需施行子宫分碎术,减小子宫体积,缩短手术时间,减少术中出血量和降低术后并发症。     

Uterine morcellation during vaginal hysterectomy: apropos of a series of 216 prospective cases

OBJECTIVE: The purpose of this study was to compare the surgical outcomes of women undergoing vaginal hysterectomy with and without morcelation. PATIENTS AND METHOD: Between December 1999 and December 2000, 216 women underwent vaginal hysterectomy without laparoscopic assistance at the Department of Gynecology of H?tel-Dieu hospital in Paris. The patients were divided into two groups: 114 of them underwent vaginal hysterectomies with morcelation whereas 102 underwent vaginal hysterectomies without morcelation. The two groups were compared as to demographic data, total complications, operative time, hospital stay length and peri-operative hemoglobin concentration change. RESULTS: Although women undergoing morcelation were significantly younger (mean 49 versus 52, p = 0.01) and less parous (mean 1.9 versus 2.3, p = 0.03), there were no significant differences in other surgical or anesthetic risks factors, including weight, BMI, nulliparity and preexisting surgical diseases. Mean uterine weight was significantly greater in those undergoing morcelation (331 versus 110 g, p < 0.001); operative time was increased in the group which had undergone morcelation (331 versus 110 g, p < 0.001). There were no significant differences between the two groups with respect to peri-operative hemoglobin concentration change or hospital stay length. Finally, the rate of surgical complication was similar in the two groups (17.5 versus 21.5%). CONCLUSION: Although vaginal hysterectomy requires an increase in operative time, morcelation at the time of vaginal hysterectomy is safe and facilitates the vaginal removal of enlarged uteri without increasing peri-operative morbidity.