Vaginal Hysterectomy Case File

Vaginal Hysterectomy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 22

A 45-year-old G4P4004 Caucasian woman presents with a 6-month history of increasing “pelvic heaviness.” She had a postpartum bilateral tubal ligation following delivery of her last child. She relates that she had a forceps delivery with her first child, and that she stands at work most of the day as a surgical scrub tech. She has also noticed increasing dyspareunia, stating that, “It feels like my partner is hitting something when we have intercourse.” She denies stress urinary incontinence, recurrent urinary tract infection, or difficulty with defecation. Her Pap smears have been normal throughout her life, and there has been no change in her menstrual pattern. She relates that 6 months of intensive Kegel exercises have not changed her symptoms. On pelvic examination, she has normal external genitalia. The vaginal mucosa demonstrates good estrogen effect, and there is adequate support of both the anterior and posterior vaginal walls. The parous cervix descends to within 1 cm of the vaginal introitus with a Valsalva maneuver. The uterus is nontender, and not enlarged, and the adnexa are not palpable. The rectal examination is unremarkable.

➤ What is the most likely diagnosis?

➤ What should be your next step?

ANSWERS TO CASE 22:

Vaginal Hysterectomy

Summary: A 45-year-old woman presents with pelvic heaviness and dyspareunia. The pelvic examination reveals that her cervix descends to the vaginal introitus with Valsalva. According to the pelvic organ prolapse quantification (POP-Q) scoring system, this is stage II pelvic organ prolapse.1

➤ Most likely diagnosis: Uterine prolapse.

➤ Next step: Vaginal hysterectomy.

ANALYSIS

Objectives

1. Understand that most benign uterine pathology requiring hysterectomy is amenable to the vaginal approach.
2. Learn the indications, advantages, and disadvantages of vaginal hysterectomy compared to abdominal or laparoscopically assisted vaginal hysterectomy.

Considerations

Uterine prolapse to the extent described in this case is a common problem for parous women, and operative vaginal delivery is increasingly felt to be a risk factor for the later development of pelvic organ prolapse. For a healthy patient who is not desirous of having any more children, vaginal hysterectomy is the procedure of choice. It is difficult to say with certainty whether a given patient’s prolapse will worsen, but it is not likely to improve over time. In comparison to total abdominal hysterectomy (TAH) or laparoscopic hysterectomy (LH), vaginal hysterectomy (VH) is faster, cheaper, safer, less painful, and most cosmetically and sexually satisfying to the patient. For benign disease, almost all types of uterine or pelvic pathology, which require hysterectomy as the therapy of choice, can be accomplished vaginally.2 The goal of this chapter is to delineate the reasons why vaginal hysterectomy should usually be the hysterectomy route of first choice for most benign gynecologic conditions requiring uterine removal.

APPROACH TO

Vaginal Hysterectomy

DEFINITIONS

VAGINAL HYSTERECTOMY: Removal of the entire uterus through the vagina. When appropriate, this is often combined with unilateral or bilateral salpingo-oophorectomy, removing one or both fallopian tubes and ovaries vaginally coincident with the hysterectomy.

TOTAL ABDOMINAL HYSTERECTOMY: Removal of the entire uterus via a laparotomy incision, whether through a vertical or transverse incision. Can likewise include removal of tubes and ovaries as above.

LAPAROSCOPIC HYSTERECTOMY: This operation has three possible variants. LAVH is aided by the laparoscope, but not to include uterine artery ligation; LH, where the laparoscope is used to ligate the uterine arteries; and TLH, in which there is no vaginal approach and the cuff is closed laparoscopically. Tubes and ovaries may also be removed via these techniques.

CLINICAL APPROACH

Hysterectomy rates in the United States are decreasing slightly, from 5.5 per 1000 women in 1990 to 5.1 per 1000 women in 2004. Abdominal hysterectomy is the most common approach, constituting 63% of all types in 1997. In April 2008, French gynecologists reported their experience comparing vaginal hysterectomy to LAVH in women who had not had prior vaginal delivery. They noted that there was less OR time, shorter hospital stay, and less cost to the patient when the vaginal approach was used. Further, as they progressed through the study and became increasingly comfortable with the vaginal approach, they relied less on the laparoscope for assistance.3 Newer techniques such as supracervical or laparoscopic hysterectomies do not have any advantages over vaginal or abdominal hysterectomies, especially in terms of avoiding complications, including urinary and sexual function. Urinary incontinence is more frequent in women who have supracervical hysterectomy than in women randomized to vaginal hysterectomy, and there is no difference in sexual function in either group, regardless of hysterectomy technique or presence of a residual cervix.4 Leaving the cervix in situ as a result of a supracervical laparoscopic procedure has been associated with an increase in later trachelectomy procedures for cyclical monthly bleeding from the cervix, for cervical dysplasia, and for prolapse of the cervical stump, all of which can be eliminated by removing the cervix at VH. If these new technologies are being questioned, it is appropriate to reiterate the benefits of VH. This discussion will focus on the indications for vaginal hysterectomy and compare vaginal hysterectomy to other hysterectomy techniques in terms of uterine size, safety, length of hospital stay, cost, and patient satisfaction, including cosmetic results and sexual function.

Indications

Vaginal hysterectomy is performed only one-third as frequently as abdominal hysterectomy in the United States. The use of systematic guidelines and algorithm protocols makes it possible to transform many, if not most, abdominal hysterectomies into vaginal procedures. Many expert national bodies and professional organizations have published the indications for hysterectomy.14 An abbreviated list of their indications includes leiomyomata in uteri, abnormal uterine bleeding, endometriosis, pelvic relaxation, pelvic pain, endometrial hyperplasia with atypia, adenocarcinoma of the endocervix when invasive disease has been excluded, and as a prophylactic procedure to include bilateral oophorectomy when there is a positive family history of ovarian cancer. There are traditional contraindications to VH that need to be reevaluated in the light of contemporary experience. Many authors have demonstrated that the enlarged uterus may be removed vaginally.5,6,7,8 Nulliparity is not a contraindication to vaginal hysterectomy, nor is a history of cesarean section. The absolute number of cesarean sections is not shown to increase the number of surgical complications.9 Planned removal of adnexal pathology does not preclude the vaginal approach, nor does a history of prior abdominal surgery.

There is concern in our specialty about the declining percentage of hysterectomies being done via the vaginal approach. Perhaps these numbers can stabilize if conditions that were traditionally viewed as being relative or absolute contraindication to vaginal hysterectomy can be perceived less dogmatically, and the decision regarding hysterectomy route can be made as objectively as possible, taking into account the pathology likely to be encountered, the desires of the patient, the experience of the surgeon, and the expense to be encountered.10

Uterine Size

Within reason, an enlarged uterus is not a contraindication to vaginal hysterectomy.11 Morcellation, bivalving, or coring facilitates removal of the large uterus, and complication rates are generally lower with the vaginal approach. Blood loss seems to be related to the size of the uterus, as does operating time, which increases in a linear fashion according to uterine weight. Studies demonstrate comparable blood loss with either the VH or the TAH.4 However, in comparison to TAH, the operating time for removing the enlarged uterus is not necessarily increased when using the vaginal approach. VH patients generally leave the hospital sooner than TAH patients. Comparisons of VH to LAVH for removal of the enlarged uterus indicate that the complication rate is higher for the LAVH, and that VH is preferable. Uteri weighing up to 280 g probably should be able to be removed vaginally by a skilled gynecologist—if vaginal removal is paramount, consider referral to an experienced vaginal surgeon when the uterine weight is expected to exceed this amount, or use an abdominal approach.

In removing the large uterus, once the uterine arteries have been secured, if leiomyomata are encountered that make removing the rest of the organ in situ difficult, then the cervix should be divided vertically with the scalpel until the body of the uterine corpus is encountered. Grasp each side of the amputated cervix with either Massachusetts clamps or single- or doubletoothed tenacula, and then reduce the size of the corpus uteri by coring it centrally with the scalpel or Mayo scissors until the reduced size of the uterus allows its removal. A myoma screw is occasionally helpful at this juncture, allowing the surgeon to obtain a grasp of a myoma with one hand while the other hand uses an instrument to excise the tumor. Patience is rewarding during this process, and blood loss is rarely a problem if the uterine arteries were secured properly when the cervix was severed. The use of the operating headlight, a long-handled scalpel, and long Mayo scissors facilitates this portion of the operative procedure.

Safety

Published articles have also noted improved secondary outcomes with VH compared to TAH, specifically regarding febrile episodes and unspecified infections.6 In those instances where VH could not be performed, they note that LH was preferable to AH, but at the greater risk of injury to the bladder or ureter. Further studies indicate that there is a significant learning curve with both VH and LH, noting that the incidence of bleeding and bowel injuries associated with VH and the incidence of ureteral and bladder injuries with LH both tend to decrease with increasing experience of the gynecologic surgeon. Several studies note that blood loss from VH is less than that from either TAH or LH.12,13 Obese women suffer fewer complications if they have VH rather than TAH. They have less OR time, less ileus, less postoperative fever and wound infections, fewer urinary tract infections, and a shorter hospital stay.

Length of Stay

Several studies have evaluated length of stay relative to type of hysterectomy performed. They conclude that VH patients had a shorter hospital stay than TAH patients, usually staying at least a day less in the hospital postoperatively. VH procedures require less operating time than LH or TAH procedures, and VH patients usually convalesce more quickly than TAH patients and are able to resume normal activity more quickly.

Cost

VH typically costs less than TAH or LH or its variants because there is less utilization of OR time, the hospital stay is shorter, and the cost of OR equipment for reusable vaginal instruments is far less than that of disposable instruments for LH.12,14 Like supracervical LH procedures, VH can also be performed in an outpatient fashion. Using carefully designed protocols based on good scientific evidence for proper patient selection, several authors report on the efficacy and reduced cost of performing VH on an outpatient basis, some discharge patients within 12 hours of admission, and note cost reductions of 20% to 25% compared to procedures requiring longer hospitalization. VH is consistently considered the most cost-effective approach. In this era of managed care, some insurance companies are still making the mistake of paying more for TAH and LH procedures than for VH approaches. It is estimated that the expense of hysterectomy is inflated by a factor of 200% to 300% because of the use of TAH and LH instead of VH. Adding the cost of the OR expense to the cost of anesthesia time yields an expense of about $50 per minute for gynecologic surgery. For the typical hospital being reimbursed a standard fee for similar procedures, the choice of VH over TAH and LH will make a huge difference in hospital costs when all of the cases are totaled at the end of a fiscal year.

Education

TAH is easier to teach and learn than VH. The view of the operative field is better for both the resident and the attending gynecologist with an open abdomen than that which can be obtained with both the surgeon and the assistants looking into the vagina. Nonetheless, responsible national organizations, hospital leadership groups, and residency training programs and education bodies recognize the benefits of VH. Implementation of the goal of making VH the standard approach requires change at the local level to implement the national efforts to increase the percentage of hysterectomies performed vaginally.15 Published reports indicate that a change in approach is possible, and that with a concerted effort, in 3 to 7 years some hospitals have completely reversed the percentages of hysterectomies done abdominally and vaginally. Residency programs that wish to increase the percentage of VH procedures have reported being able to do so over the course of several years, without a concomitant increase in the complication rate. In most hospital settings, the senior gynecologists with many years of operating experience are the most proficient vaginal surgeons. Many articles have suggested that, in addition to increasing the number of VH procedures in residency, the concept of using these senior physicians as mentors for newly minted gynecologists will increase the proficiency of the new staff members as vaginal surgeons.16

Sexual Function and Cosmetic Results

Claims that leaving the cervix in place as an advantage of supracervical hysterectomy for better sexual function and orgasmic response have not been supported by any confirmatory studies in the medical literature. Extensive studies over the past several years have shown that improvements in sexual desire, activity, and coital frequency all increase after recovery from hysterectomy, whether VH or TAH. Scores for vaginismus, lack of orgasm, loss of sexual interest, and dyspareunia all decreased after recovery from hysterectomy.17 Women who have had TAH have more of a negative body image because of the abdominal scar, and they have more postoperative pain and a slower recovery than did the patients in the VH groups.17 Women who were sexually active prior to hysterectomy tend to remain sexually active following hysterectomy, without encumbrance from the pathology necessitating hysterectomy in the first place.

Technique

Gynecology is the only specialty in which the physician is uniquely trained to work inside the vagina. A successful vaginal surgeon appreciates the finesse of his/her skill, and learns that millimeters of exposure and meticulous dissection measure the difference between success and failure when working vaginally. He/she learns to regard the Heaney clamp as a functional extension of his/her hands, Russian forceps as transmitting a tactile sense which he/she can discern in his/her fingertips, and a needle driver in his/her grasp as secure and steady in an operative site where he/she is specifically trained to operate (Figures 22–1 through 22–5).

Figure 22–1. Vaginal mucosa incised circumferentially. (Reproduced, with permission, from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery, 9th ed.New York: McGraw-Hill, 2010:1505.)

Figure 22–2. The anterior cul-de-sac is entered sharply. (Reproduced, with permission, from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery, 9th ed.New York: McGraw-Hill, 2010:1505.)

Figure 22–3. The pedicles are suture-ligated. (Reproduced, with permission, from Brunicardi FC,Andersen DK,Billiar TR, et al.Schwartz’s Principles of Surgery,9th ed.New York: McGraw-Hill, 2010:1505.)

Figure 22–4. The uterus is completely excised. (Reproduced, with permission, from Brunicardi FC,Andersen DK,Billiar TR, et al.Schwartz’s Principles of Surgery,9th ed.New York: McGraw-Hill, 2010:1505.)

Figure 22–5. The vaginal cuff is closed. (Reproduced, with permission, from Brunicardi FC,Andersen DK,Billiar TR, et al.Schwartz’s Principles of Surgery,9th ed.New York: McGraw-Hill, 2010:1505.)

Comprehension Questions

22.1 A 42-year-old woman consults you for a second opinion regarding her proposed hysterectomy. The initial gynecologist told her that a supracervical hysterectomy was the procedure of choice, rather than vaginal hysterectomy, because she would not be able to have orgasm without her cervix. What is your response?

A. You agree with her first gynecologist.

B. You tell her that there is no scientific evidence that removing her cervix will alter her sexual function, and that most studies demonstrate that regardless of the surgical route of her hysterectomy, her sexual function is likely to improve once she completely recovers from her surgery.

C. You tell her that you will refer her for sexual counseling postoperatively.

D. You plan to treat her with testosterone following surgery.

22.2 A 37-year-old patient has symptomatic uterine leiomyomas, and ultrasound confirms an enlarged uterus which you estimate weighs 250 g. Her friends tell her that she should have an abdominal hysterectomy because her uterus is too big to be removed safely via the vaginal route. What do you tell her?

A. You agree with her friends and schedule her for an abdominal hysterectomy.

B. You propose a laparoscopic hysterectomy as an alternative.

C. You tell her that you believe you can do the hysterectomy vaginally, and that you will begin using that approach, but that you are prepared to operate abdominally if necessary to complete the operation safely.

D. You propose myomectomy as an alternative.

22.3 A 35-year-old woman weighing 275 lb (124.74 kg) requires hysterectomy for menorrhagia not responsive to hormone therapy or endometrial ablation. She is afraid of vaginal hysterectomy because she believes that she will bleed excessively. What do you tell her?

A. You agree with her and schedule an abdominal hysterectomy.

B. You ask her to store blood in the blood bank for use at surgery.

C. You tell her that most scientific studies have indicated that her blood loss will be less vaginally than abdominally.

D. You schedule her for laparoscopic hysterectomy.

ANSWERS

22.1 B. The route of hysterectomy does not have any advantage in terms of sexual function. The cervix is not necessary for orgasm.

22.2 C. An enlarged uterus is not a contraindication to vaginal hysterectomy.

22.3 C. Several studies have shown that vaginal hysterectomy is associated with less blood loss than either abdominal or laparoscopic hysterectomy.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Infiltrate the vaginal mucosa at six equidistant sites around the cervix at the proposed incision site with a mixture of 1% with 1:100,000 epinephrine, or vasopressin, to reduce intraoperative blood loss (Level B).

➤ Use a headlight, or instruments such as retractors or suction instruments with a light source attached, when performing vaginal surgery. Standard OR lights are rarely bright enough, do not focus sharply, and never are at an optimum angle for seeing how to work in the vagina (Level C).

➤ If the vaginal hysterectomy is not accompanied by colporrhaphy, avoid the use of a Foley catheter. Tell the patient she will arrive in the recovery room with a full bladder, and that she will be encouraged to void in recovery. If unable to void, she may be straight-catheterized twice over the next 6 to 8 hours, and should have a Foley placed only after the third failed voiding attempt. Over 75% of patients will never need a Foley (Level B).

➤ Close the vaginal cuff vertically rather than horizontally if there is concern about maintaining adequate vaginal length. Horizontal closure shortens the vagina by about 1 cm; vertical closure does not significantly change vaginal length (Level B).

REFERENCES

1. Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10-17. The classic treatise describing the POPQ system for quantifying pelvic organ prolapse. 

2. Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2006 Apr;19(2):CD003677. 

3. Le Tohic A, Dhainaut C, Yazbeck C, Hallais C, Levin I, Madelenat P. Hysterectomy for benign uterine pathology among women without previous vaginal delivery. Obstet Gynecol.2008;111:829-837. 

4. Gimbel H, Zobbe V, Anderson BM, Filtenborg T, Gluud C, Tabor A. Randomised controlled trial of total compared with subtotal hysterectomy with one-year follow up results. BJOG. 2003;110:1309-1318. 

5. Paparella P, Sizzi O, Rosetti A, De Benedittis F, Papaarella R. Vaginal hysterectomy in generally considered contraindications to vaginal surgery. Arch Gynecol Obstet. 2004;270:104-109. 

6. Makinen J, Johansson J, Tomas C, et al. Morbidity of hysterectomies by type of approach. Hum Reprod. 2001;16:1473-1478. 

7. Jacobsen G, Shaber R, Armstrong M, Hung Y. Hysterectomy rates for benign indications. Obstet Gynecol. 2006;107:1278-1283. 

8. Doucette R, Sharp H, Alder S. Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol. 2001;184:1386-1389. 

9. Poindexter Y, Sangi-Haghpeykar H, Poindexter A, et al. Previous cesarean section. A contraindication to vaginal hysterectomy? J Reprod Med. 2001;46:840-844. 

10. Julian TJ. Vaginal hysterectomy. An apparent exception to evidence-based decision making. Obstet Gynecol. 2008;111:812-813. 

11. Unger J. Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams. Am J Obstet Gynecol. 1999;180:1337-1344. 

12. Levy B, Luciano D, Emery L. Outpatient vaginal hysterectomy is safe for patients and reduces institutional cost. J Minim Invasive Gynecol. 2005;12:494-501. 

13. Olah K, Khalil M. Changing the route of hysterectomy: the results of a policy of attempting the vaginal approach in all cases of dysfunctional uterine bleeding. Eur J Obstet Gynecol Reprod Biol. 2006;125:243-247. 

14. Lefebvre G, Allaire C, Jeffrey J, et al. SOCG clinical guidelines. Hysterectomy. J Obstet Gynaecol Can. 2002;24:37-61. 

15. Kovac S. Transvaginal hysterectomy: rationale and surgical approach. Obstet Gynecol. 2004;103:1321-1325. The definitive paper justifying vaginal hysterectomy, with an excellent algorithm to determine the correct surgical approach for a given patient. 

16. Gutl P, Greimel E, Roth R, Winter R. Women’s sexual behavior, body image and satisfaction with surgical outcomes after hysterectomy: a comparison of vaginal and abdominal surgery. J Psychosom Obstet Gynaecol. 2002;23:51-59. 

17. Taylor S, Romereo A, Kammerer-Doak D, Rogers R. Abdominal hysterectomy for the enlarged myomatous uterus compared with vaginal hysterectomy with morcellation. Am J Obstet Gynecol. 2003;189:1579-1582. 

18. Darai E, Soriano D, Kimata P, Laplace C, Leduru F. Vaginal hysterectomy for enlarged uteri, with or without laparoscopic assistance; randomized study. Obstet Gynecol. 2001;97:712-716. 

19. Falcone T, Walters MD. Hysterectomy for benign disease. Obstet Gynecol. 2008;111:753-767. A definitive paper in the “clinical expert series” from the green journal.

HomeGynecologic Surgery Case FileVaginal Hysterectomy Case File