Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy

OBJECTIVE: We compared operative time, length of hospital stay, postoperative recovery, return to work, and costs for women undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy. STUDY DESIGN: A prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy (n = 24) versus abdominal hysterectomy (n = 24) was carried out in a tertiary care setting. The main outcome variables were operative time, length of hospital stay, and return to work. Secondary outcomes were postoperative pain and return to normal activity as determined by weekly visual analog scales and daily diary. Hospital costs were calculated. RESULTS: The laparoscopically assisted vaginal hysterectomy group had longer operative times (median and quartiles, laparoscopically assisted vaginal hysterectomy 180 [139, 225] minutes vs abdominal hysterectomy 130 [97, 155] minutes), lower requirements for postoperative intravenous analgesia (patient-controlled analgesia pump, median and quartiles: laparoscopically assisted vaginal hysterectomy 22.1 [15.9, 23.5] hours, abdominal hysterectomy 36.7 [26.2, 45.0] hours), shorter length of hospital stay (median and quartiles, laparoscopically assisted vaginal hysterectomy 1.5 [1.0, 2.3] days, abdominal hysterectomy 2.5 [1.5, 2.5] days), and quicker return to work (Kaplan-Meier analysis, P =.03). Both procedures had similar hospital costs (P =.21). CONCLUSION: Laparoscopically assisted vaginal hysterectomy appears to allow patients a more rapid postoperative recovery and an earlier return to work with hospital costs similar to those of abdominal hysterectomy.     

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.     

Choosing the Route of Hysterectomy

Purpose

To compare the clinical results of three techniques of hysterectomy- abdominal hysterectomy (AH), non-descent vaginal hysterectomy (NDVH), and laparoscopic-assisted vaginal hysterectomy (LAVH).

Methods

A simple prospective randomized study was performed in a tertiary care centre between June 2011 and Dec 2012, among 150 consecutive women indicated to undergo hysterectomy for benign and mobile uterine conditions. They were randomly assigned 50 each to three routes of hysterectomy; (abdominal, vaginal, and laparoscopic-assisted vaginal). Outcome measures including operating time, blood loss, rate of complications, consumption of analgesics, and length of hospital stay were assessed and compared between groups.

Results

As far as duration of operation, mean blood loss, analgesic requirement, length of hospital stay, P value was significant. Incidence of complications is least among VH group.

Conclusion

Vaginal hysterectomy is the gold standard in the era of minimal access surgery. Some of the contraindications to VH can be overcome by assistance of laparoscope and a potential abdominal hysterectomy can be converted to a vaginal procedure.     

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.     

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.     

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.     

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.     

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.     

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.     

Short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy and total abdominal hysterectomy

STUDY OBJECTIVE: To compare short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH). DESIGN: Retrospective cohort study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: One hundred fifty women who underwent LAVH and 146 who underwent TAH. INTERVENTION: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: Blood loss during surgery, narcotic analgesic consumption, duration of hospital stay, and convalescence time were significantly higher for women who underwent TAH than for those who underwent LAVH (p <0.05). Operating time was significantly longer for LAVH than for TAH (152.2 +/- 32.4 vs 96.5 +/- 29.6 min, p = 0.014). Eight-year follow-up showed no statistically significant differences in vaginal vault prolapse, cystocele, rectocele, enterocele, postcoital spotting, and cuff granulation between procedures (p >0.05). CONCLUSIONS: Although short-term clinical results revealed some statistically significant differences between LAVH and TAH, long-term follow-up recorded similar frequencies of surgical sequelae.     

Gonadotropin-releasing hormone agonist use before hysterectomy

OBJECTIVE: Our purpose was to compare the effects of leuprolide acetate in patients with symptomatic uterine leiomyoma before hysterectomy. STUDY DESIGN: Group I (n = 90) included patients with a pretreatment uterine size of 14 to 18 gestational weeks and group II (n = 60) included patients with uteri >18 weeks' gestational size. Patients in both groups were randomized to either immediate hysterectomy or 2 months of preoperative gonadotropin-releasing hormone agonist. RESULTS: All patients in the two groups with a pretreatment hemoglobin <11.0 gm/dl randomized to agonist had a significant (p < 0.05) increase (≥1.5 gm/dl) in hemoglobin level. Patients in group I who received preoperative agonist were more likely to undergo vaginal hysterectomy (80% vs 13%, p < 0.05) than were patients who did not receive preoperative agonist. Patients undergoing vaginal hysterectomy had a shorter hospital stay, decreased operative blood loss, and a shorter convalescence period than did those undergoing abdominal hysterectomy. In group II, in spite of a mean uterine volume reduction of 51.3%, intraoperative morbidity, operative blood loss, hospital stay, and postoperative convalescence period did not differ between treatment arms. CONCLUSION: The preoperative administration of gonadotropin-releasing hormone agonist in patients with a uterus of 14 to 18 weeks' size increases the use of vaginal hysterectomy, decreases intraoperative blood loss, and shortens hospital stay and convalescence. Preoperative gonadotropin-releasing hormone agonist for patients with a preoperative hemoglobin <11.0 gm/dl reduces the risk of preoperative transfusion. Preoperative gonadotropin-releasing hormone use in the nonanemic patient with a uterine size ≥18 weeks' gestational size does not appear to lower operative morbidity. (AM J Obstet Gynecol 1994;170:1744-51.)     

Nondescent vaginal hysterectomy: a constantly improving surgical art

Objective

This study was undertaken to check the feasibility of the vaginal route as the primary route for all hysterectomies, in the absence of uterine prolapse, for benign conditions.

Methods

During 2005 to 2007 an effort was made to perform as many hysterectomies vaginally with or without oophorectomy in women with benign or premalignant conditions in the absence of prolapse. Severe endometriosis, immobility of the uterus, uterine size more than 18 weeks and malignancy were excluded. Patients were classified into two groups — Group I — uterine size up to 12 weeks, with no risk factors and Group II — uterine size 12–18 weeks or with confounding factors like, mild to moderate endometriosis, nulliparity or LSCS in the past. The outcome was compared between the two groups and abdominal hysterectomies done for benign conditions. Statistical analysis was done by SE(d) between mean and proportion.

Results

A total of 164 cases nondescent vaginal hysterectomies were done. Of these, 92 (56.1%) were in group I and 72 (43.9%) in group II. The operation time in Group II was significantly more than in group I (81.3 minutes with SD of 31.4 s. 62.6 minutes SE(d) between 2 means-7.49). Debulking techniques were required in 58.7% of the cases in group II compared to 2.1% in group I. Both the groups had one conversion each. The peroperative blood loss, pain score, hospital stay and return to normal activity, was comparable in both the groups of vaginal hysterectomy (VH) and significantly superior to those undergoing abdominal hysterectomies for benign conditions.

Conclusion

The vaginal approach is possible in most benign conditions requiring hysterectomy and is superior to the abdominal route with respect to recovery and complication rates.     

Changing the route of hysterectomy: the results of a policy of attempting the vaginal approach in all cases of dysfunctional uterine bleeding

OBJECTIVE: To assess the effectiveness of a policy of performing a vaginal hysterectomy for as many cases of dysfunctional uterine bleeding without uterine prolapse as possible between 1997 and 2003. STUDY DESIGN: The study was prospective, with retrospective analysis of data. SETTING: Warwick Hospital. POPULATION: Eighty-seven women in a district hospital serving a population of 270,000 in South Warwickshire. METHODS: During 1997 and 2003, an effort was made to perform as many hysterectomies vaginally as possible, with oophorectomy where necessary, in women with dysfunctional uterine bleeding in the absence of prolapse. The trends of the three different operations, total abdominal hysterectomy, sub-total abdominal hysterectomy and vaginal hysterectomy over the 7-year period were analysed. MAIN OUTCOME MEASURES: The ability to undertake surgery successfully, complications rates, length of hospital stay and changes in surgical practice. RESULTS: Over this 7-year period, it has proved possible to change the emphasis from abdominal to vaginal hysterectomy for dysfunctional uterine bleeding. In 1997, the most common operation for dysfunctional uterine bleeding (72.7%) was subtotal hysterectomy+/-bilateral salpingo-oophorectomy, followed by (27.3%) total abdominal hysterectomy+/-bilateral salpingo-oophorectomy. No cases were undertaken vaginally. By 2003, however, the trend had completely reversed, with the only procedure undertaken being vaginal hysterectomy+/-bilateral salpingo-oophorectomy. There is no evidence that such an approach increases the complication rate, and the recovery rate from surgery is improved with a tendency towards earlier discharge in the vaginal surgery group. CONCLUSION: The vaginal approach is possible for an average gynaecologist working in a district general hospital, with no additional complications and an improved recovery rate for patients.     

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.)     

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.     

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.     

Vaginal sacrocolporectopexy for the surgical treatment of uterine and vaginal vault prolapses: confirmation of the surgical method and perioperative results of 101 cases

Purpose

In this study, we sought to confirm the surgical method of vaginal sacrocolporectopexy and previously reported positive perioperative results of this procedure in a large patient group. We describe the approach which offers a vaginal, safe alternative to sacrospinous repair, laparoscopic or open vaginosacropexy and the use of synthetic meshes to treat pelvic organ prolapse.

Methods

We conducted a monocentric, prospective, nonrandomized study for treatment of patients with uterine and vaginal vault relapse (grade 2–4). All patients underwent a preoperative urogynecological urodynamic examination. We focus on method, operative time, complications, blood transfusions, hospital stay and clinical data.

Results

Between March 2006 and March 2011, 101 consecutive patients of mean age 64 (40–89) years, with sub or total uterine prolapse (n?=?69, grade 2–4) and vaginal vault prolapse (n?=?32, grade 2–4) were treated with vaginal sacrocolporectopexy. Cystocele (grade 2–4) was found in 88 (87.1?%) and rectocele (grade 2–4) in 43 (42.5?%) patients. Mean duration of surgery with sacrocolporectopexy was 70?min (28–165) without hysterectomy, and 76?min (40–219) with hysterectomy. Regression analysis of all patients (n?=?101) showed a significant decrease of operative time in the group without hysterectomy after 40 cases. Three bladder lesions, two in patients with a history of hysterectomy, occurred during surgery and were corrected intraoperatively without further complications. No patient required a blood transfusion. Hemoglobin levels decreased slightly from a preoperative mean of 13.6?mg/dl (10.3–15.7) to a postoperative mean of 11.7?mg/dl (8.6–14.7).

Conclusion

Vaginal sacrocolporectopexy is a safe vaginal method for the treatment of sub-/total uterine/vaginal vault prolapse.     

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.     

Colposacropexia por laparoscopia en el tratamiento del prolapso genital

Objectives

To analyze the results of laparoscopic colposacropexy and to achieve a long-lasting support system without recurrences.

Material and methods

From March 2001 to March 2007, we performed laparoscopic colposacropexy in 42 patients. The mean age was 56 years (42-70 years).Patients with prior hysterectomy showed complex vaginal vault prolapse while those without hysterectomy showed prolapse affecting more than one compartment. The 28 women with pelvic uterine prolapse underwent hysterectomy (supracervical hysterectomy in 15 and total hysterectomy in 13). The transperitoneal Burch procedure was carried out in eight patients with stress urinary incontinence.

Results

The mean length of follow-up was 3.5 years (range: 1-6). Surgery was successful in 39 patients (92.8%). Anterior compartment recurrence was observed in one patient and severe lumbar pain associated with postoperative spondylodiscitis in another patient. A third patient required posterior trachelectomy. The mean operating time was 180 min (range: 120-240). The mean length of hospital stay was 2.5 days (range: 2-3).

Conclusions

Laparoscopic colposacropexy is a safe and constantly evolving procedure with longterm durability. This procedure provides similar results to laparotomy but produces fewer vaginal complications.     

Vaginal hysterectomy for benign disorders in obese women: a prospective study

OBJECTIVE: To compare the morbidity of vaginal hysterectomy in obese and non-obese women in a single institution. DESIGN: Obese and non-obese women with benign uterine disorders matched for age, parity and race underwent vaginal hysterectomy without laparoscopic assistance. Peri-operative outcome complications were compared. Thirty-eight women had a BMI over 30 kg/m(2) (study group) and 178 women had a BMI below 30 kg/m(2) (control group). SETTING: Gynaecologic department of a university hospital. POPULATION: Women who were referred to our department with an indication of vaginal hysterectomy for benign disorders. METHODS: Case control study. MAIN OUTCOME MEASURES: Peri-operative complications, the fall in the haemoglobin concentration, the duration of the procedure, the length of the hospital stay and uterine weight were analysed. RESULTS: Mean BMI was 33.2 and 23.7 kg/m(2) in the study and control groups, respectively. None of the obese women had severe co-morbidity contraindicating surgery. There were no significant differences in surgical or anaesthetic risk factors, including parity, hormonal status, pre-existing disease and estimated mean uterine weight. The overall complication rates were 14% and 16% in the obese and non-obese groups, respectively (P= 0.7). Obesity did not increase the duration of the procedure (48 [7] minutes vs 50 [10] minutes, P= 0.1) or the length of hospitalisation (5.8 [1.4] days vs 5.5 [1.2] days, P= 0.2). CONCLUSION: Vaginal hysterectomy can be successfully performed, with acceptable morbidity, in obese women.