Arch Gynecol Obstet (2004) 270:104–109 DOI 10.1007/s00404-003-0505-x

ORIGINAL ARTICLE

Pierluigi Paparella · Ornella Sizzi · Alfonso Rossetti · Franco De Benedittis · Raffaele Paparella

Vaginal hysterectomy in generally considered contraindications to vaginal surgery Received: 1 February 2003 / Accepted: 11 March 2003 / Published online: 10 July 2003
Springer-Verlag 2003

Abstract Objective: The objective was to evaluate the feasibility and complication rate of vaginal hysterectomy with or without adnexectomy in women with enlarged uteri and/or other considered contraindications to the vaginal route. Study design: Over a period of 2 years, a total of 204 women underwent vaginal hysterectomy for benign pathology. Normally considered contraindications to the vaginal route were: moderate to excessive uterine enlargement, nulliparity or no prior vaginal delivery, previous cesarean or pelvic surgeries and adnexal pathologies. Laparoscopy was used only if it became necessary. Patients with uterine prolapse were excluded. The clinical outcomes and complication rate were analyzed even with regards to the type of contraindication. Results: The mean age of the patients was 46.96€4.8 years (range: 38–68). The mean uterine weight was 427.74€254.75 g (range: 150–2,000). The operative time ranged from 30 to 140 min (mean: 61.59€21.80 SD) for vaginal hysterectomy alone, increasing up to 170 min (mean: 83.6€38.28 SD) in case of adnexectomy or laparoscopic assistance. The patient characteristics, the uterine weight and the postoperative results and clinical outcome did not differ among the groups of contraindications. Overall, the complication rate was 9.8%. No patient required a transfusion for surgical blood loss, a return to the operating room or readmission to the hospital. During vaginal hysterectomy, adnexectomy was possible in 90.6% of the cases in which it was indicated (unilateral in 21.8% because of adnexal pathology) and was technically impossible in 9.3%. In 4 cases (1.9%) it was not possible to complete vaginal hysterectomy owing to the presence of thick adhesions obliterating the cul-deP. Paparella · O. Sizzi · A. Rossetti · F. De Benedittis · R. Paparella Division of Gynecologic Endocrinology, Complesso Integrato Columbus, Via Moscati 31, 00168 Rome, Italy P. Paparella ()) Via Roccaraso 19, 00135 Rome, Italy e-mail: [email protected] Tel.: +39-06-3503755 Fax: +39-06-3720814

sac, of severe endometriosis or other unforeseen circumstances. In these few cases with a difficult access to the ovaries (2.9% of all VH) or with difficulties in mobilizing the uterus, we resorted to laparoscopy. The pneumoperitoneum was achieved by means of an insufflation tube inserted via the vagina into the abdominal cavity and packing the vagina. Thus, the risks associated to the insertion of the Veress needle were avoided. In all but two cases in which conversion to laparotomy was necessary, laparoscopy was successfully completed. Conclusions: Vaginal hysterectomy appears to be feasible in about 97% of cases in which this approach would have been judged unsuitable. This figure decreases to 94.2% when oophorectomy is indicated. Keywords Vaginal hysterectomy · Vaginal oophorectomy · Large uterus · Complications · Laparoscopy

Introduction Hysterectomy remains the treatment of choice in most women with leiomyomas of the uterus. Despite the fact that vaginal hysterectomy is associated to a lower morbidity and to a more rapid post operative recovery than abdominal hysterectomy [5, 7, 29], this technique is not frequently performed in patients with uteri which are enlarged owing to the presence of myomas or extensive adenomyosis [26]. A number of pre-existing clinical conditions are generally accepted as contraindications to vaginal hysterectomy: moderate to excessive uterine enlargement, nulliparity or no prior vaginal delivery, previous cesarean or pelvic surgeries and adnexal pathologies or the indication to oophorectomy [8]. The rationale for our study is the statement that the vaginal route is to be preferred every time the anatomical conditions allow it and every time the nature of the lesions to be treated does not contraindicate it. The aims of our study were to evaluate the feasibility and complication rate of vaginal hysterectomy in women

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with enlarged uteri and other traditionally considered contraindications to this surgical technique. In an effort to completely avoid the abdominal route, laparoscopy was resorted to in those cases in which, owing to technical difficulties, it was impossible to complete hysterectomy via the vaginal route.

Materials and methods Having obtained the Institutional Ethics Board approval, 204 consecutive women with an enlarged uterus weighing between 280 and 2,000 g and/or with one or more of the following commonly considered contraindications to vaginal surgery (previous pelvic surgery, history of pelvic inflammatory disease, moderate or severe endometriosis, concomitant adnexal masses or other indications to adnexectomy, nulliparity with lack of uterine descent and limited vaginal access) were enrolled in this prospective study between November 1999 and December 2001. With regards to the uterine size, no upper limit was set. Exclusion criteria were pelvic prolapse or relaxation or uteri weighing <280 g in the absence of other traditional contraindications. With the exception of oncologic pathologies, no woman was candidate to abdominal surgery in this period. Total laparoscopic hysterectomies (10.7% of cases) were scheduled in women with vaginas narrower than two fingers wide and/or with immobile uterus with no lateral mobilization. Indications for vaginal hysterectomy included: a growing uterus with myomas, abnormal uterine bleeding or menorrhagia attributable to the presence of uterine myomas and myomas associated to adnexal pathology. The patients were divided into five groups on the basis of the following preoperative criteria: 1. 2. 3. 4. 5.

A large uterus (>280 g) The presence of adnexal pathology Nulliparity Previous cesarean section or other pelvic surgery More than one “contraindications”

The groups were studied and compared for the operative indications, demographic characteristics, concomitant procedures (adhesiolysis, cystectomy, uterine morcellation, etc.), the total operative time, the hospital stay, the use of analgesics, the perioperative change in hemoglobin levels and surgical complications. We evaluated the following data: the patients’ age and weight (in kilograms), parity, previous vaginal delivery, previous pelvic surgery (cesarean section, myomectomy, etc.), the presence of adnexal pathologies or endometriosis and the uterine weight (in grams). Sixty patients were scheduled to undergo bilateral oophorectomy at the time of surgery for standard indications; in 14 patients unilateral adnexectomy was performed owing to the presence of adnexal pathology. Two surgeons, one experienced in vaginal surgery and one experienced in laparoscopy performed all the procedures. Vaginal hysterectomy was performed according to the modified Heaney technique. In those cases in which adnexectomy was technically impossible owing to a problematic access to the ovary or in which uterine mobilization was impossible because of the presence of thick adhesions, we converted to laparoscopy. The insufflation tube was inserted through the vagina into the abdominal cavity, the vagina was packed with a soaked pad to maintain the pneumoperitoneum obtained without the use of the Veress needle. The umbilical primary trocar was introduced and the procedures successfully completed. Complications were classified as: 1. Intraoperative events 2. Intraoperative bleeding necessitating transfusion

3. 4. 5. 6. 7.

Infections A fall in hemoglobin levels 4 g/dl Operative injury to the bladder, bowel or ureters Postoperative complications necessitating redo surgery Readmission to the hospital

Conversion to laparoscopy was not considered as an intraoperative complication because laparoscopy permitted us to avoid abdominal surgery. Prophylactic antibiotics were administered intravenously to all patients just before surgery. The operative time was calculated from the anesthesia chart and included the induction of anesthesia and the positioning of the patient. The preoperative hemoglobin concentration was compared with that observed on postoperative day 1 and the perioperative hemoglobin concentration change thus calculated. Postoperative fever was considered to be body temperature 38C in two consecutive measurements at least 6 h apart, excluding the first 24 h. The hospital stay was tracked in whole days. In order to verify, for the variables age, patient weight, operative time, hospital stay and Hb levels, existing, if any, significant differences among all five groups, the analysis of variance (ANOVA) model was used. This analysis was integrated with post-hoc comparisons between relevant groups using the LSD Test. The t-test, the multiple regression model and the analysis of variance (ANOVA) model were used to evaluate the relationship between the operative time, adnexectomy, the different groups and uterine weight. Differences between the groups regarding the hospital stay and the necessity of analgesics were analyzed using the Kruskal-Wallis (ANOVA by ranks) test. A p value <0.05 was considered as statistically significant. All analyses were performed using the Statistica Software for Windows (StatSoft Inc., 1997).

Results The indication for hysterectomy was fibroids in all 204 cases; associated pathologies included abnormal uterine bleeding or menorrhagia in 64 patients and adnexal disease in 28 (Table 1). No patient had utero-vaginal prolapse. The mean age of the patients was 46.96€4.8 SD years (range 38–68). Thirty-four were nulliparous and the mean parity of the remaining 170 was 1.94€0.71 SD (range 1–4). Thirty-two patients had undergone pelvic surgery and 14 had been delivered by cesarean section. The mean uterine weight was 427.74€254.75 SD g (range: 150–2,000). With regards to the patients undergoing vaginal hysterectomy, 124 were included in Group 1 (patients with a large uterus), 28 in Group 2 (myomas associated to adnexal pathology), 16 in Group 3 (myomas and nulliparity), 18 in Group 4 (myomas and previous pelvic surgery) and 18 in Group 5 (myomas associated to more than one other commonly Table 1 Primary indications for the performance of total hysterectomy Indication

Patients (n)

%

Fibroids Fibroids and abnormal uterine bleeding or menorrhagia Fibroids and adnexal pathology

112 64

54.9 31.4

28

13.7

106 Table 2 Demographic characteristics of patients and outcome measures. NS not significant All patients (n=204) 46.96 Age (years)a Weight (kg)a 68.98 Paritya 1.94 Nulliparous womenb 34 Previous laparotomyb 34 Adnexal pathologyb 30 a Uterine weight (g) 427.74 Operative time (min)a 61.59 Laparoscopic Conversionb 10 (4.9%) a DHb 1.36 Hospital staya (days) 2.94 Analgesic requirement (days) 0.74

Adnexal pathology (n=28) 47.43 69.14 1.86 0 0 28 293.21 68.00 0 1.02 3.36 0.57

Nulliparity (n=16) 49.13 61.00 16 0 0 348.75 55.62 0 0.73 3.13 0.6

Previous surgery (n=18)

Enlarged uterus (n=124)

46.56 65.11 2.11 0 18 0 407.78 52.50 2 (11.1%) 1.2 2.67 0.9

46.66 69.61 1.94 0 0 0 452.48 62.52 8 (6.45%) 1.45 2.90 0.7

More than one contraindication (n=18) 46.78 75.33 18 16 2 556.67 71.00 0 (0%) 1.87 2.67 0.66

p value

NS* p<0.01c*

NS* NS* NS* NS** NS**

a Mean b Percentage c

Patient weight was higher in the group with more than 1 contraindication * ANOVA model. A p value <0.05 was considered as statistically significant ** Krustal-Wallis test Table 3 Complications of vaginal hysterectomy

Overall rate Intraoperative conversion Postoperative overall Postoperative infection, unexplained fever urinary tract infection Blood transfusion Vaginal cuff bleeding Re-operation Re-admission

All patients

Adnexal pathology (n=28)

Nulliparity (n=16)

Previous surgery (n=18)

Large uterus (n=124)

More than one contraindication (n=18)

p value

20 2 18 12 4

2 0 2 2 0

2 0 2 2 0

0 (0%) 0 (0%) 0 (0%) 0 0

14 0 14 8 4

2 (11.1%) 2 (11.1%) 0 (0%) 0 0

NSa

0 2 0 0

(9.8%) (0.9%) (8.8%) (5.8%) (1.7%)

0 0 0 0

(7.1%) (0%) (7.1%) (7.1%)

(12.5%) (0%) (12.5%) (7.1%)

0 0 0 0

0 0 0 0

(11.3%) (0%) (11.3%) (6.4%) (3.2%)

0 2 (1.6%) 0 0

NSa

0 0 0 0

* ANOVA model. A p value <0.05 was considered as statistically significant

considered contraindications). These data are shown in Table 2. The operative time ranged from 30 to 140 min (mean: 61.59€21.80 SD) for vaginal hysterectomy, increasing up to 170 min (mean 83.6€38.28 SD) in case of adnexectomy or laparoscopic assistance. A linear relationship between the uterine weight and the operative time was not statistically confirmed although the latter increased with the weight of the uterus. There were no statistically significant differences among the groups as to the mean age, parity, pre- and post-operative hemoglobin levels and the mean uterine weight. The postoperative necessity of analgesics and the length of hospital stay did not differ among the groups. The only statistically significant difference was the patient weight, which was higher in the group with more than one commonly considered contraindications (p<0.01) (Table 2). Vaginal morcellation of the uterus was carried out in all cases. The morcellation techniques used were the Lash intramyometrial coring, uterine bisection, myomectomy

and wedge debulking. Several different morcellation procedures were often used in the same woman. The operative complications are summarized in Table 3. Two cases of intraoperative hemorrhage and two of postoperative bleeding occurred. In no case was blood transfusion necessary. Sixteen patients presented with postoperative fever or febrile infections. Thus, the overall complication rate was 9.8%. In no case was redo surgery or readmission to the hospital necessary. One intraoperative conversion to abdominal surgery was necessary in a patient with a uterus weighing 2,000 g and a history including previous pelvic surgery. Thick adhesions between the bladder and uterus and adhesions obliterating the posterior cul-de-sac were present. Bleeding occurred during vaginal anterior dissection and it was decided to proceed via the abdominal route. The same situation occurred in a nulliparous patient with a history of pelvic surgery and endometriosis of the cul-de-sac and a uterus weighing 1,800 g. There were no statistically significant differences in the complication rates of the five groups of patients (Table 3)

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During vaginal hysterectomy, adnexectomy was possible in 90.6% of the cases in which it was indicated (unilateral in 21.8% because of adnexal pathology). The additional operative time required to remove the ovaries vaginally varied from 10 to 30 min (mean: 21.41 min). Ovariectomy was technically impossible in 9.3% of the cases in which it was indicated. In these six cases (2.9% of VH), the adnexa were laparoscopically removed after vaginal hysterectomy. In 1.9% of cases, it was impossible to complete the vaginal hysterectomy: in 3 cases because of the presence of severe endometriosis and thick adhesions obliterating the cul-de-sac and impeding the access to the pouch of Douglas; in 1 case, at the end of the vaginal morcellation, a last remaining piece of the uterine fundus was accidentally pushed inside the abdominal cavity and was hence no longer retrievable. Laparoscopy revealed the presence of thick adhesions between the uterine fundus and the abdominal wall at the level of the umbilicus. These were successfully lysed. In all these cases, laparoscopic assistance allowed us to complete the vaginal hysterectomy. All the TLH procedures were successfully carried out.

Discussion Compared to VH, TAH is associated with an increased morbidity rate [5, 11], a higher complication rate, an increased hospital stay and a less rapid recovery. Nevertheless, abdominal hysterectomy exceeds vaginal hysterectomy for benign disease by an at least 3:1 ratio or more in most countries (Table 4) [1, 4, 10, 13, 28, 29]. Traditional contraindications to vaginal surgery include an enlarged uterus, a history of pelvic pain or endometriosis, previous pelvic surgery, nulliparity and indications for oophorectomy. These contraindications have been challenged by several authors who have reported doing vaginal hysterectomy in the presence of one or more contraindications without a significant increase in the complication rate [8, 9]. The indications for vaginal versus abdominal hysterectomy appear to vary from one institution to another and seem to be based more on personal preferences rather than on the hard evidence reported in the literature [19]. The style of practice and surgical experience of the physician have been identified as important variables

Table 4 Surgical procedures used to perform hysterectomy: review of the literature

Study (reference)

[13] [10] [4] [1] ISTAT (1999)a Present study (2002) a

Country

USA Finland UK France Italy Italy

influencing the decision to perform hysterectomy by a specific technique [6, 16]. Studies similar to the present suggest that uterine enlargement should not be considered as a contraindication to vaginal hysterectomy [8, 17, 26]: vaginal hysterectomy should be considered even in the presence of considerable uterine enlargement. No matter how large the uterus, once the uterosacral and cardinal ligaments have been divided, the uterine vessels can be quite easily secured [17]. Previous pelvic surgery, including cesarean delivery, is regarded as a relative contraindication to vaginal hysterectomy [12], although scanty data in the literature do not support this statement [2, 25, 27]. In the present series, the surgical morbidity rate in the group with previous pelvic surgery was not significantly different to that observed for patients in the groups without a history of abdominal surgery. No case of injury to the bladder, which could be considered as the major potential problem with vaginal hysterectomy after previous cesarean delivery, was reported. Wilcox et al. [29], analyzing data from the National Hospital Discharge Survey on hysterectomy in the United States from 1988 to 1990, stated that although prophylactic adnexectomy was performed in 85% of the patients older than 45 years who underwent abdominal hysterectomy, the same procedure was performed in only 18% of patients who underwent vaginal hysterectomy. Some gynecologists are advocating oophorectomy as an indication for laparoscopically-assisted vaginal hysterectomy [20, 27]. Certainly, the indications for ovarian removal should be similar regardless of whether an abdominal, laparoscopic or vaginal hysterectomy is being performed [15]. In the present series, prophylactic oophorectomy was scheduled in all menopausal patients but one who refused to sign the informed consent for oophorectomy. The rate of totally vaginal oophorectomy without laparoscopic assistance (90.6%) is similar to that reported by surgeons with experience in vaginal surgery [3, 14, 23, 24]. The more frequent causes of failure were tuboovarian adhesions, endometriosis and vaginal inaccessibility. In a study of 128 hysterectomies in which morcellation was required, Mazdinian et al. reported that 16% of the planned vaginal hysterectomies were not successfully completed [18]. Kovac [14] was able to perform vaginal hysterectomy in 97% of patients having the presumptive Surgical procedure (hysterectomy) Abdominal %

Vaginal %

Laparoscopic %

46.4 83.8 71.7 43.4 66.0 0.9

20.7 10.9 20.1 47.0 33.0 87.6

32.9 5.3 8.2 9.6 1.0 11.5

Data of the Italian Institute of Statistics, personal communication

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needle and primary trocar. Besides, such an approach may not be necessary in all patients even in cases with considered contraindications or risk factors or when oophorectomy is required. In our series adnexectomy was successfully carried out in 90.6% of the cases in which it was indicated. This, even in the presence of adnexal pathologies. In 94.2% of cases previous pelvic surgery did not negatively influence the outcome of surgery. It has to be pointed out that, in 3.2% of cases, the problems that arose were completely unexpected and occurred in the absence of known pelvic disease or previous pelvic surgery.

Conclusions Vaginal hysterectomy appears to be feasible in about 97% of women for whom, according to other reports [14, 22], this approach would have been judged unsuitable. Laparoscopic conversion allowed us to complete the vaginal hysterectomy in another 1.9% of cases, reducing to the minimum the necessity of abdominal hysterectomy (0.9%). Fig. 1 Flowchart of the Authors’ guidelines for choosing the route of hysterectomy for benign pathologies

risk factors that are often believed to mandate abdominal hysterectomy. Laparoscopic surgery was necessary to permit a transvaginal operation in only 19% of considered pre-operative indications for laparoscopically assisted vaginal hysterectomy. Doucette [8] vaginally completed all the hysterectomies thus challenging the generally accepted contraindications to vaginal hysterectomy. However, the size of the uterus he reported was smaller than that we observed in the present study (>180 g vs. >280 g). In our series it was necessary to convert to an abdominal route in 2 cases. The failures would have been 6 had we not converted to laparoscopy in 4 patients. In our series the failure rate was 2.9%. Laparoscopy succeeded in completing hysterectomy in all cases but 2. It has to be stressed that according to other reports [18], conversion to an abdominal hysterectomy because of a technical inability to complete the planned vaginal procedures was not associated to an increased operative morbidity. In our earlier experience laparoscopically assisted vaginal hysterectomy was intended to replace some of the abdominal hysterectomies. Since then, we have learned that in most cases hysterectomy could have been performed vaginally even in case of commonly considered risk factors (Fig. 1). Moreover, in most cases laparoscopically assisted vaginal hysterectomy increases costs and the operative time. This, not to mention the risks related to the access technique itself. At the moment we do not feel that it is advisable to start the procedure with a diagnostic laparoscopy and thus expose the patient to the additional risks associated to the insertion of the Veress

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