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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, National Taiwan University Hospital, and Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Methods: A total of 452 patients receiving LAVH or transvaginal hysterectomy were retrospectively studied between October 2002 and October 2004. The operative time, estimated blood loss, uterine weight, and complications were all recorded for analysis.
Results: Significant linear correlations of uterine weight with operative time and estimated blood loss could be seen only in the transvaginal hysterectomy group. Transvaginal hysterectomy required significantly shorter operative time, but longer duration when the uterine weight exceeded 350 g. These 452 patients were stratified into 4 subgroups according to the uterine weight and hysterectomy procedure. Data are expressed as the mean ± standard deviation. For uterine weight less than 350 g, transvaginal hysterectomy had significantly shorter operative time than LAVH (80 ± 27 minutes compared with 118 ± 21 minutes, P < .05) but similar blood loss (70 mL compared with 74 mL). For uterine weight 350 g or less, transvaginal hysterectomy had not only significantly longer operative time (139 ± 30 minutes compared with 118 ± 17 minutes, P < .05) but also more blood loss (242 ± 162 mL compared with 66 ± 51 mL, P < .05) than LAVH.
Conclusion: In view of the shorter operative time and less blood loss, LAVH is preferable for uterine weight 350 g or more, whereas transvaginal hysterectomy is better in dealing with uteri weighing less than 350 g.
Level of Evidence: II-2
In a randomized trial, Summitt et al8 found that outcomes for transvaginal hysterectomy were similar to those for LAVH, but with significantly lower costs. Richardson et al9 concluded that LAVH is a waste of time and money. Despite convincing evidence that transvaginal hysterectomy is more favorable and can be done successfully in most women with enlarged uteri,6,7,10,11 increased operative time is usually needed.9,11,12 Surgeons may encounter greater risks when dealing with a large uterus, eg, a protracted procedure and potential complications challenging their operative skills and patience. In addition, significant blood loss remains a major disadvantage in removing a larger uterus, in which access to the uterine vessels sometimes becomes difficult or even impossible. A clear consensus exists that the mainstay of hysterectomy is to secure the blood supply.9,16–18 As the world's first surgeon to perform a laparoscopic hysterectomy, Reich16 emphasized in his review that the sine qua non for LAVH is ligation of the uterine vessels.
A surgeon's reluctance to perform vaginal procedures due to a lack of training or experience, especially in dealing with a significantly enlarged uterus, may contribute to the preference for LAVH. The only formal guideline available is the uterine size by the American College of Obstetricians and Gynecologists, and transvaginal hysterectomies are preferred in women with a uterus no larger than 12 weeks of gestation size (approximately 280–300 g).19 A recent study by Kovac20 favored transvaginal hysterectomy for uterine weight less than 280 g, and some reports21,22 have demonstrated the benefits of LAVH in dealing with a much larger uterus. A rationale for the guideline is still needed.
The aims of this study were to compare the surgical characteristics, including operative time, estimated blood loss, complications, and hospital stay between transvaginal hysterectomy and LAVH and to estimate a cutoff value of uterine weight as a rational guideline for better hysterectomy procedures.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This study was approved by the Institutional Review Board of the hospital. The basic clinical characteristics of the patients, including age, body mass index, obstetric history, prior pelvic surgery, and preoperative diagnoses were recorded at admission. In addition, the operative time, estimated blood loss, uterine weight, complications, and hospital stay were also recorded before discharge.
The patients underwent either LAVH or transvaginal hysterectomy without specific clinical bias preoperatively. The hysterectomies were performed by a team mainly composed of the senior authors (S.C.H. and D.Y.C.). Transvaginal hysterectomy is performed according to the procedure described by Joel-Cohen.23 Briefly, patients were put in the lithotomy position. After thorough disinfection, diluted vasopressin solution (0.1 U/mL normal saline) was injected along the vaginal fornices, and a circumferential incision was subsequently made along the uterine cervix. The vesicocervical and cardinal-uterosacral ligaments were clamped, cut, and respectively suture-ligated. The vesicouterine peritoneum was opened after the vesicocervical space had been created, and the posterior cul-de-sac was opened in a similar manner. The uterine vessels were secured at the bilateral isthmic levels, and "Heaney"-type procedures were carried out along the broad ligaments up to the bilateral uterine cornua. Volume-reducing techniques, including bisection, coring, morcellation, enucleation or a combination of these procedures, were used if necessary.
For LAVH, patients were placed in Allen stirrups with knees flexed and thighs abducted but not flexed at the hips. A uterine manipulator was introduced through the vagina before the abdominal incision. A 10-mm trocar was inserted first through the umbilicus to hold the optic camera. A 5-mm trocar along with another 10-mm trocar was inserted in the lower abdomen. The stage-IV LAVH9 began with electrocoagulation and transection of the bilateral round ligaments. In patients who desired to preserve the adnexa, the Fallopian tube and ovarian ligament were transected, whereas in those who preferred a salpingo-oophorectomy, the infundibulopelvic ligaments were isolated, ligated, and transected. Bilateral uterine arteries were identified and ligated by extracorporeal ties through retrograde umbilical ligament tracking, and the vesicouterine peritoneum was opened to make the subsequent hysterectomy easier to perform. The vaginal procedures began with anterior and posterior colpotomies. The vesicocervical, cardinal, and uterosacral ligaments were transected. After the uterine vessels and the adnexal collaterals had been secured laparoscopically, various volume-reducing techniques could be performed at the surgeon's discretion.
The operative time was calculated from the first incision to the end of wound closure. Blood loss was estimated by summation of the volume of blood in the suction bottles and calculating the weight difference of the gauze used before and after surgery. The removed uterus was freshly weighed before fixation in formalin. Complications were defined as those events requiring active treatment or a prolonged hospital stay.
Data are expressed as mean ± standard deviation unless stated otherwise. The comparisons of selected measurers related to the basic clinical and surgical characteristics between transvaginal hysterectomy and LAVH were performed by t test for continuous variables and 
2 or Fisher exact test for categorical variables. The statistical analysis of the parameters in 4 stratified subgroups was conducted by analysis of variance. Pair-wise comparisons between subgroups were analyzed with Bonferroni correction for multiple comparisons. Multiple linear regression analysis was further used to investigate whether the correlations between operative time, estimated blood loss, and hysterectomy procedures differed by uterine weight. All statistical analyses were performed with SPSS 10.1 for Windows (SPSS Inc., Chicago, IL). A P < .05 was considered statistically significant.
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RESULTS |
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We stratified these patients by uterine weight, beginning at 200 g and scaling up 50 g. Data inTable 2 show that the operative time in the LAVH group remained constant regardless of the uterine weight. On the contrary, the operative time in the transvaginal hysterectomy group became longer with increasing uterine weight. Generally, transvaginal hysterectomy required shorter operative time than LAVH, but significantly longer duration was needed when the uterine weight exceeded 350 g, which might be taken as a cutoff value. Therefore, we further stratified these patients into 4 subgroups: uterine weight less than 350 g (small uterus) with transvaginal hysterectomy or LAVH and uterine weight 350 g or more (larger uterus) with transvaginal hysterectomy or LAVH.
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The surgical characteristics and clinical outcomes of these stratified patients are shown inTable 3. The average operative time (139 minutes) in the transvaginal hysterectomy group with larger uteri was significantly longer than that (118 minutes) in LAVH group, regardless of uterine weight, and longer than that (80 minutes) in the transvaginal hysterectomy group with small uteri. Patients in the transvaginal hysterectomy group with larger uteri had much greater average estimated blood loss than that of the other groups (242 mL compared with 66 mL, 70 mL, and 74 mL, P < .05), and 1 of them required a transfusion for excessive hemorrhage (600 mL). All patients had flatus passage, oral intake, and ambulation within 2 days after the operation. Few postoperative analgesics were needed in these patients. One patient in the transvaginal hysterectomy group with small uteri had a bladder injury, which was repaired primarily through the vaginal route; she recovered without adverse sequelae. There was no ureter or bowel injury in any patient. No statistically significant differences in complication rates were found. There was no reoperation or mortality. All patients were followed up at our clinic at least 3 months after the operation, and no specific complications had been noted.
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Figure 1 shows that there was a significant linear correlation between operative time and uterine weight in the transvaginal hysterectomy but not the LAVH group. It also confirmed the results inTable 3 that transvaginal hysterectomy was associated with significantly longer operative time in patients with larger uteri, and a similar result was seen on estimated blood loss (data not shown). When putting all related clinical measures in multivariate models to examine the interaction between uterine weight and types of operation on operative time and estimated blood loss, we found a significant interaction between uterine weight (
350 g compared with < 350 g) and type of operation (LAVH compared with transvaginal hysterectomy) (P < .001 for operative time and estimated blood loss, respectively).
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DISCUSSION |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In this study, we found that the LAVH group had longer operative time and a larger uterine size than the transvaginal hysterectomy group. However, after further stratifying these patients by uterine weight, we found a significantly longer operative time for transvaginal hysterectomy than LAVH when setting the cutoff value at 350 g. The average operative time was much shorter in the transvaginal hysterectomy group (80 minutes for transvaginal hysterectomy compared with 118 minutes for LAVH, P < .05) when the uterine weight was less than 350 g, whereas a reverse condition could be seen (139 minutes for transvaginal hysterectomy compared with 118 minutes for LAVH, P < .05) when the uterine weight was 350 g or more (Table 3). In addition, we found more blood loss specifically in the transvaginal hysterectomy group with uterine weight 350 g or more (242 mL compared with 66 mL, 70 mL, and 74 mL), and 1 of the patients required a transfusion for excessive bleeding (600 mL). A positive linear correlation between uterine weight and estimated blood loss in the transvaginal hysterectomy group was also seen. On the contrary, neither operative time nor estimated blood loss was affected by uterine weight in the LAVH group.
Laparoscopically assisted vaginal hysterectomy is a useful adjunct to transvaginal hysterectomy for lysis of extensive adhesions and sometimes for certain concomitant adnexal surgery. Besides, LAVH can also secure almost all the main blood supplies to the uterus, ie, the uterine vessels and the adnexal collaterals.9,16–18 Although a skilled surgeon can do transvaginal hysterectomy with a larger uterus by employing volume-reducing techniques, Kohler25 reported that laparoscopic coagulation hemostasis of the uterine vessels was associated with less blood loss. In this study, we routinely ligated the bilateral uterine arteries and the adnexal collaterals during our stage-IV LAVH. It may take time to achieve these goals, but they may make subsequent extirpation or volume-reducing procedures easier and safer to perform. Because the uterine vessels were secured and the vesicouterine peritoneum was opened in advance at the laparoscopic phase, subsequent vaginal volume-reducing procedures could be done at the surgeon's discretion. Therefore, the average operative time and estimated blood loss for the LAVH remained almost constant regardless of increasing uterine weight.
Uterine volume plays an important role and can be roughly estimated. It is conventionally expressed by the relative gestational week. To assess the uterine weight in grams before a hysterectomy is guesswork. However, preoperative ultrasonography is important to access a fibroid site and for determining its dimensions when planning for enucleation, morcellation, or both. A good pelvic examination under anesthesia by an experienced practitioner further leads to confidence and relevance in the decision-making process. Both LAVH and transvaginal hysterectomy can be used for a nonprolapsed uterus. Generally, the average operative time for LAVH was longer than that for transvaginal hysterectomy. It takes time to secure the uterine blood supply before extirpation and volume-reducing procedures, but it also makes LAVH superior to transvaginal hysterectomy when dealing with a larger uterus. In our opinion, LAVH might be considered for a larger uterus in view of the relatively shorter operative time and less blood loss, whereas transvaginal hysterectomy is preferable for a small uterus, not only for shorter operative time and minimal wound, but also for much lower costs.
Despite the statistically significant differences in blood loss and operative time between transvaginal hysterectomy and LAVH for larger uteri (both being higher in the transvaginal hysterectomy group), both measures were still quite reasonable in the transvaginal hysterectomy group (242 mL and 139 minutes, respectively). Bleeding of more than 500 mL occurred in only 1 patient with a large uterus undergoing transvaginal hysterectomy. No other severe complications were significantly more common in the transvaginal hysterectomy group. Although LAVH is preferable for uterine weight 350 g or more in view of the relatively shorter operative time and less blood loss, even women who underwent transvaginal hysterectomy with uteri that weighed at least 350 g did very well. This study was limited to surgeries on nonprolapsed uteri only, which are technically more challenging. Prolapsed uteri are substantially easier to remove by transvaginal hysterectomy. Both transvaginal hysterectomy and LAVH are acceptable for removing a larger uterus, especially when considering the higher costs of the LAVH.
This study is a retrospective review of charts, and the limitation is that the choice of hysterectomy procedures was dependent on the surgeons. Even if by the process of backward matching we are able to configure our 4 groups so that they exhibit similar levels of other suspected causes, we have at most very tentative evidence for the causal link in question. Therefore, the findings in this study should be considered preliminary at this time, and further randomized and prospective studies are necessary.
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Footnotes |
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doi:10.1097/01.AOG.0000171106.39216.17
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REFERENCES |
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2. Olsson J, Ellstrom M, Hahlin M. A randomized prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynaecol 1996;103:345–50.[Medline]
3. Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano G. Laparoscopic assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol 1999;180:270–5.[Medline]
4. Kovac R, Cruikshank S, Retto H. Laparoscopy assisted vaginal hysterectomy. J Gynecol Surg 1990;6:185–93.[Medline]
5. Hillis S, Marchbanks P, Peterson H. Uterine size and risk of complications among women undergoing abdominal hysterectomy for leiomyomas. Obstet Gynecol 1996;87:539–43.[Abstract]
6. Benassi L, Rossi T, Kaihura CT, Ricci L, Bedocchi L, Galanti B, Vadora E. Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial. Am J Obstet Gynecol 2002;187:1561–5.[Medline]
7. Hwang J, Seow K, Tsai Y, Huang L, Hsieh B, Lee C. 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. Acta Obstet Gynecol Scand 2002;81:1132–8.[Medline]
8. Summitt R, Stovall T, Steege J, Lipscomb G. A multicenter randomised comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol 1998;92:321–6.[Abstract]
9. Richardson R, Bournas N, Magos A. Is laparoscopic hysterectomy a waste of time? Lancet 1995;345:36–41.[Medline]
10. Magos A, Bournas N, Sinha R, Richardson R, O'Connor H. Vaginal hysterectomy for the large uterus. Br J Obstet Gynaecol 1996;103:246–51.[Medline]
11. Unger J. Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams. Am J Obstet Gynecol 1999;180:1337–44.[Medline]
12. Deval B, Rafii A, Soriano D, Samain E, Levardon M, Darai E. Morbidity of vaginal hysterectomy for benign tumors as a function of uterine weight. J Reprod Med 2003;48:435–40.[Medline]
13. Harmanli OH, Gentzler CK, Byun S, Dandolu V, Grody MHT. A comparison of abdominal and vaginal hysterectomy for the large uterus. Int J Gynaecol Obstet 2004;87:19–23.[Medline]
14. Wang P, Lee W, Yuan C, Chao H, Liu W, Yu K, et al. Major complications of operative and diagnostic laparoscopy for gynecologic disease. J Am Assoc Gynecol Laparosc 2001;8:68–73.[Medline]
15. Mazdisnian F, Kurzel R, Coe S, Bosuk M, Montz F. Vaginal hysterectomy by uterine morcellation: an efficient, non-morbid procedure. Obstet Gynecol 1995;86:60–4.[Abstract]
16. Reich H. Laparoscopic hysterectomy. Surg Laparosc Endosc 1992;2:85–8.[Medline]
17. Darai E, Soriano D, Kimata P, Laplace C, Lecuru F. Vaginal hysterectomy for enlarged uteri, with or without laparoscopic assistance: randomized study. Obstet Gynecol 2001;97:712–6.
18. Kohler C, Hasenbein K, Klemm P, Tozzi R, Schneider A. Laparoscopic-assisted vaginal hysterectomy with lateral transsection of the uterine vessels. Surg Endosc 2003;17:485–90.[Medline]
19. Precis I. An update in obstetrics and gynecology. CD-ROM. Washington, DC. American College of Obstetricians and Gynecologists; 1989.
20. Kovac S. Hysterectomy outcomes in patients with similar indications. Obstet Gynecol 2000;95:787–93.
21. Pelosi M, Kadar N. Laparoscopically assisted hysterectomy for uteri weighing 500 g or more. J Am Assoc Gynecol Laparosc 1994;1:405–9.[Medline]
22. Nimaroff M, Dimino M, Maloney S. Laparoscopic-assisted vaginal hysterectomy of large myomatous uteri with supracervical amputation followed by trachelectomy. J Am Assoc Gynecol Laparosc 1996;3:585–7.[Medline]
23. Joel-Cohen S. Abdominal and vaginal hysterectomy: new techniques based on time and motion studies. Philadelphia (PA): Lippincott; 1977.
24. Doucette R, Sharp H, Alder S. Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol 2001;184:1386–9.[Medline]
25. Kohler C, Hasenbein K, Klemm P, Tozzi R, Michels W, Schneider A. Laparoscopic coagulation of the uterine blood supply in laparoscopic-assisted vaginal hysterectomy is associated with less blood loss. Eur J Gynaecol Oncol 2004;25:453–6.[Medline]
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