Vaginal hysterectomy is preferable for benign uterine pathology even in women without previous vaginal delivery, according to a report in the April Obstetrics & Gynecology.
"The advantages of the vaginal route (with or without laparoscopy) are numerous for patients and for society," Dr. Arnaud Le Tohic from Bichat-Claude Bernard University Hospital in Paris told Reuters Health. "Hospital stay is shorter, there is no (or really short) scar which is cosmetically better for patients, pain is lower, analgesic use is lower, recovery is faster, and finally cost is lower for everyone."
Dr. Le Tohic and colleagues evaluated the course and outcome of vaginal hysterectomies performed over a 9-year period in 300 nulliparous women.
In approximately three-quarters of cases, vaginal hysterectomy was elective. In these circumstances, the success rate was 92.1%. Overall, 69.7% of vaginal hysterectomies in the nulliparous women were successful.
Reasons for conversion from vaginal hysterectomy to laparotomy included excessive uterine volume or a contracted genital tract, pelvic adhesions, anesthetic complications, and, in one case, a bladder lesion.
Compared with laparotomy, vaginal hysterectomy was associated with shorter hospital stays, the report indicates. Furthermore, mean operative time was longest with a vaginal approach with laparoscopic assistance (160 minutes) and shortest with an exclusively vaginal approach (75 minutes). Mean operative time for laparotomy was 120 minutes.
Over the 9 years of the study, the rate of abdominal hysterectomies remained stable and the rate of vaginal hysterectomy increased significantly, but the rate of laparoscopic-assisted vaginal hysterectomies decreased significantly.
"The vaginal route (eventually with laparoscopic assistance in certain cases) should be tried as often as possible because it is nearly always possible when tried after a good exam under general anesthesia, even if uterus is enlarged (in our series, median uterine weight for vaginal route was about 350 grams)," Dr. Le Tohic said. "The vaginal route must be taught for all gynecologist surgeons."
"Laparotomy in first intention (and in case of hysterectomy for benign uterine pathology, prolapse excluded) should only be the choice for very large uteri after examination under general anesthesia," Dr. Le Tohic added.
In a related editorial, Dr. Thomas M. Julian of the University of Wisconsin School of Medicine and Public Health in Madison refers to Dr. Le Tohic's team as a "group of talented French gynecologic surgeons." Their report, he says, confirms that "the time-honored contraindications to vaginal hysterectomy are not contraindications in most cases."
"Unfortunately it seems nonpragmatic to think that we could popularize vaginal hysterectomy after 30 years of decline," Dr. Julian writes. "I would very much like our residency training programs, gynecologic surgical societies, certifying organizations, gynecologists in practice, and an educated public to prove me wrong."
Obstet Gynecol 2008;111:812-813,829-837.
Reviewed By Ramaz Mitaishvili, MD
