vaginal-hysterectomy

November 9, 2009 — The American College of Obstetricians and Gynecologists (ACOG) advocates vaginal hysterectomy as the safest, most cost-effective method to remove the uterus for noncancerous reasons, according to a new committee opinion published in the November issue of Obstetrics & Gynecology.

"Vaginal hysterectomy is better for women in terms of fewer complications and quicker recoveries compared with abdominal or laparoscopic surgery," Cheryl B. Iglesia, MD, chair of ACOG's Committee on Gynecologic Practice, from Washington Hospital Center in Washington, DC, said in a news release. "Vaginal hysterectomy also is the most cost-effective method."

Currently available approaches for surgical removal of the uterus are vaginal, abdominal, or with laparoscopic or robotic assistance. Choice of the route and method for hysterectomy should consider optimal safety and cost-effectiveness based on each patient's medical needs.
Of the roughly 600,000 hysterectomies done annually, 40.7% are performed for fibroids, 17.7% for endometriosis, and 14.5% for uterine prolapse. The approach used is abdominal in 66%, vaginal in 22%, and laparoscopic in 12%. Factors to consider in choosing the best route for hysterectomy in a particular patient include vaginal and uterine size and shape; accessibility to the uterus; surgeon experience and training; extent of disease; informed patient preference; and available hospital technology, devices, and support.

Research to date supports generally better outcomes and fewer complications with vaginal hysterectomy vs laparoscopic or abdominal hysterectomy. Compared with abdominal hysterectomy, vaginal hysterectomy is associated with shorter hospitalization, more rapid return to normal activity, and fewer febrile episodes or unspecified infections. Compared with laparoscopic hysterectomy, vaginal hysterectomy is associated with shorter operating time.

When vaginal hysterectomy is not feasible, surgical options include laparoscopic hysterectomy, robot-assisted hysterectomy, or abdominal hysterectomy. Compared with abdominal hysterectomy, laparoscopic hysterectomy is associated with more rapid resumption of usual activities, shorter hospitalization, reduced decline in hemoglobin levels and in blood loss during surgery, and fewer infections of the surgical wound or abdominal wall. However, operating time is longer, and there is a higher rate of lower urinary tract injuries involving the bladder and ureter.

"Experience with robot-assisted hysterectomy is limited at this time; more data are necessary to determine its role in the performance of hysterectomy," the ACOG Committee on Gynecologic Practice writes. "The decision to electively perform a salpingoophorectomy should not be influenced by the chosen route of hysterectomy and is not a contraindication to performing a vaginal hysterectomy."
Specific recommendations of the ACOG Committee on Gynecologic Practice are as follows:
Based on the well-documented advantages and lower complication rates of vaginal hysterectomy, this is the approach of choice whenever feasible.

The route of hysterectomy does not affect the decision of whether to perform prophylactic oophorectomy at the time of hysterectomy. This choice should be determined by the patient's age, risk factors, and informed preference.
For women in whom a vaginal hysterectomy is not indicated or is not feasible, laparoscopic hysterectomy is an alternative to abdominal hysterectomy.

Because of currently limited experience with robot-assisted hysterectomy, more data are needed to evaluate its role in performing hysterectomy.
"The paramount concern is that we provide the safest procedure for our patients," Dr. Iglesia said. "That being said, based on the national data, it's pretty clear that more hysterectomies in the US could be performed using the less invasive vaginal approach than are currently being done."
Obstet Gynecol. 2009;114:1156-1158.

Clinical Context

Approximately 600,000 women undergo hysterectomy each year in the United States. The most common indication for hysterectomy is symptomatic leiomyomata, followed by endometriosis and uterine prolapse.
Two thirds of all hysterectomies are performed abdominally, whereas only 22% are vaginal hysterectomies. Patient factors influencing the decision to proceed with abdominal vs vaginal hysterectomy include the shape of the vagina and uterus, the extent of uterine disease, and the need for concurrent procedures. The current review compares surgical techniques and offers recommendations for surgeons performing hysterectomy for benign conditions.

Study Highlights

If the vagina allows access to divide the uterosacral and cardinal ligaments, the uterus can usually be made mobile enough to allow for vaginal hysterectomy. This means that women with a narrow pubic arch or an undescended uterus may be eligible for vaginal hysterectomy.
In cases with an enlarged uterus, techniques such as wedge morcellation, uterine bisection, and intramyometrial coring can effectively reduce uterine size when performing vaginal hysterectomy.

Conversely, severe extrauterine disease such as adnexal pathologic disorders or adhesions may prevent vaginal hysterectomy. These cases may be evaluated with a laparoscope before hysterectomy to judge the best surgical technique.
The decision to perform a salpingo-oophorectomy should not be influenced by the route of hysterectomy. The success of removing the ovaries vaginally ranges from 65% to 97.5%.

Overall, vaginal hysterectomy is the preferred route for removing the uterus. A systematic review found that vaginal hysterectomy is associated with the following advantages vs abdominal hysterectomy:
Shorter duration of hospital stay
Faster return to normal activity
Fewer febrile episodes or unspecified infections
Lower costs

Vaginal hysterectomy is also associated with a shorter operating time vs laparoscopic hysterectomy.
When vaginal hysterectomy cannot be performed, laparoscopic hysterectomy is generally preferred vs abdominal hysterectomy because of the following advantages:
Shorter duration of hospital stay
Faster return to normal activity
Lower intraoperative blood loss
Fewer wound or abdominal wall infections
However, laparoscopic hysterectomy is associated with longer operating times and a higher rate of lower urinary tract injuries vs abdominal hysterectomy.
Experience with robot-assisted hysterectomy for benign conditions is limited, and more research should evaluate the relative efficacy and safety of this procedure.

Clinical Implications

The most common indication for hysterectomy in the United States is symptomatic leiomyomata, followed by endometriosis and uterine prolapse.

The current recommendations state that vaginal hysterectomy is the preferred route for removing the uterus in cases of benign disease.