IMPLICATIONS OF HYSTERECTOMY ON VAGINAL ROUTE IN GYNECOLOGIC PATHOLOGY

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2016 vol. 120, no. 3 SURGERY ORIGINAL PAPERS IMPLICATIONS OF HYSTERECTOMY ON VAGINAL ROUTE IN GYNECOLOGIC PATHOLOGY V. Bulimar*, I. Costea, M. Glod, R. Terinte University of Medicine and Pharmacy Grigore T. Popa -Iasi Faculty of Medicine Department of Surgery *Corresponding author. vbulimar@hotmail.com IMPLICATIONS OF HYSTEROCTOMY ON VAGINAL ROUTE IN GYNECOLOGIC PATHOLOGY (Abstract): Vaginal hysterectomy was mentioned before our era by Soranus of Ephesus, and it is one of the most frequent surgical interventions in gynecologic practice; performed for the first time by Sauter of Constance, in 1822, who practiced a vaginal hysterectomy without ligation of vessels, carrying out the hemostasis with a swab dipped in alum. The essential argument for vaginal surgery is the advantages it brings. Current indications and contraindications encourage the frequent use of vaginal hysterectomy in benign pathol o- gy of the uterus, while the indication (Crossen, Rouhier, Campbell techniques) depends most of the times on the surgeon s experience and preference rather than on the critic evaluation of results. Material and methods: The study group included 84 patients, hospitalized from January 2013 to December 2015 in the Third Obstetrics Clinic. For the evaluation of results, we used longitudinal retrospective clinical-statistical method. Results and discussion: Practicing the surgery on vaginal route is mainly indicated in patients with severe anemias and different organic tares. When removal of the cervix is not indicated, or when there is an enlarged uterus or one with a small diameter, it is recommended to use laparoscopic hysterectomy. Conclusions: Vaginal hysterectomy is a technique that allows rapid removal of the uterus, with a minimal impact on the patient, indicated in the pathology of benign uterine tumors (uterine fibromatosis associated with metrorrhagia, fibromatous uterus with cervical dysplasia, or fibromatous uterus associated with different degrees of uterine prolapse). Keywords: VAGINAL HYSTEROCTOMY, BENIGN TUMORAL CONDITIONS, HEM- ORRHAGE. When the size of the uterus is not very big, hypogastrium does not have many adherences, there are no pathological changes and if the diameter of the vagina allows, hysterectomy on vaginal route is possible, either under epidural anesthesia with a total limitation of mobility and senses, or under general anesthesia (1). For patients, it is more comfortable, while the operatory time, hospitalization days and recovery time are shorter than in cases of abdominal interventions. Vaginal hysterectomy is an accepted method in patients with uterine descensus, whose basins allow vaginal surgery, whose tumors are small enough to allow the vaginal technique, and if the patients consent to be operated via vaginal route (1,2). When there are large fibromas, pretreatment with a GnRH analogue will allow 581

2 V. Bulimar et al. the vaginal surgery, which was previously impossible (3,4). Removing the uterus and cervix, also the stability of the vagina is reduced, as well as the future onset of a vaginal prolapse by applying special sutures; rarely there can be inflammations and/or bleedings, which can be shortly resolved by medical treatment or short local vaginal treatments (6,7). In November 2009, ACOG (The American Congress of Obstetricians and Gynecologists), through the Committee on Gynecologic Practice, published an opinion that recommended vaginal hysterectomy as the safest and the most cost-effective method of uterus removal for nonneoplastic indications. Without changing the eligibility criteria for vaginal hysterectomy issued in 1989, the authors pointed out the fact that the surgeons can decide, depending on their technical skills, to use VH (vaginal hysterectomy) even when there are apparent contraindications (8). The paper aims at highlighting particularities on the place and value of hysterectomy on vaginal route in resolving the most frequent surgical gynecologic conditions (uterine fibroma, conditions of genital apparatus associated with chronic diseases, septic states, advanced age, and organic tares). MATERIAL AND METHODS The study group of the retrospective longitudinal study included 84 patients, hospitalized from January 2013 to December 2015 in Elena Doamna Clinical Hospital of Obstetrics and Gynecology of Iasi, under the service of Third Clinic of Obstetrics-Gynecology. The inclusion criterion was preoperative indication of hysterectomy for benign pathology. The information was collected from the patients observation charts, surgical interventions register and histopathological records. We monitored the features of the field age, environment of origin, number of cases of vaginal hysterectomy for the associated uterine pathology (benign tumors) and the diseases of the adnexa s, as well as the advantages and disadvantages of the method. RESULTS AND DISCUSSION Although hysterectomy is a surgical routine, its costs and morbidity in relation to this intervention had a significant economic impact on the health and social systems (8). Within the period of time included in the study, 84 cases of vaginal hysterectomy were performed (tab. I), with various distributions on age groups (tab. II). TABLE I Yearly distribution of the cases of vaginal hysterectomy Year Vaginal hysterectomy No. % Total TABLE II Structure on age groups Group (years) No. % Under

3 Implications of hysterectomy on vaginal route in gynecologic pathology The frequency of obstetrical antecedents showed insignificant differences in relation with the number of pregnancies (tab. III). TABLE III Obstetrical antecedents of the study group Frequency of births in antecedents No. % Similar to other authors (9,10), we evaluated in our study the possible risks related to the nature of obstetrical and gynecologic antecedents, presence of comorbidities, drug allergies and ongoing therapies. Vaginal hysterectomy in benign tumor pathology needs lab investigations: CBC (Complete Blood Count), blood type, glycaemia, urea, creatinine, coagulogram, urinalysis, urine culture, as well as cytological and bacteriologic examination of vaginal discharge. In some cases, it is possible to practice electrocardiogram, pulmonary radioscopy, echography with vaginal ultrasound probe, or intravenous urography. To eliminate neoplastic pathology, we performed biopsy curettage a month prior to surgical intervention, and to prevent post operatory infection, we administered second generation cephalosporin intra operatory, or 500 mg metronidazole, intravenous. When cervix removal is not indicated, or there is an enlarged uterus, or a small diameter of vagina, laparoscopic hysterectomy is recommended. Thus, on one hand, the pathogenic agents in vagina don t reach the abdominal organs, and on the other hand, the stability of hypogastrium is maintained. When choosing the vaginal route, we considered the anatomical condition of each case, mobility of the uterus and the vaginal caliber (11,12). A special situation arises when the polyfibromatous uterus is associated with different degrees of genital prolapse and stress urinary incontinence (tab. IV, fig.1). TABLE IV Some indications of vaginal hysterectomy Main indications Cases No. % Uterine fibromatosis associated with different de- grees of uterine prolapse Uterine fibromatosis associated with metrorrhage Fig.1. Indications for vaginal hysterectomy 583

4 V. Bulimar et al. We obtained special results in cases with prolapse; hysterectomy was supplemented by a suspension of the bladder and vaginal stump through the straps of the adnexa and ligaments, plus anterior colporraphy and posterior colpoperineorraphy. Although other authors, too (10,11) admit that the main complications after vaginal hysterectomy can be stump hematoma, local infection, bladder and intestinal wounds, the most important complications are intra- or post operatory bleedings, infection, lesions of neighboring organs, thromboembolic complications etc. The surgeon may decide, according to its technical possibilities of the use VH even in the presence of an apparent contraindication. During the vaginal hysterectomy, predictable bleedings occurred in 3(3.57%) cases (bleeding from the vaginal trance, difficulties of detachment from myometrium from myometrium); 2 (2.38%) cases with accidental losses of blood due to incorrect ligatures, their secondary sliding and accidental rupture of vascular pedicles; 11(1.14%) patients presented delayed post operatory bleeding, in the third week, caused by the active bleeding from the vaginal stump. The complications we faced consisted of one case with vaginal stump abscess and two cases with bladder lesions due to close adherences; 6% needed surgical intervention. TABLE V Post operatory complications occurring in the study group Cases Complication No % Bleeding Bladder lesions We evaluated the results post operatory one month, two months, four months and one year after the surgery. Vaginal hysterectomy makes that the main changes arising post operatory are determined by the absence of the uterus from the pelvis, with redistribution of abdominal pressure on the pelvic floor. As any other type of hysterectomy, it can cause emotional changes which can be easily prevented by means of post operatory discussions and adequate treatment, including hormonal therapy (tab. V). DISCUSSION Vaginal route allows wide access of intrapelvic genital organs, wide array of gynecologic surgeries of the uterus and adnexa, from the simplest ones, such as myomectomy, salpingectomy, tubal ligation, to total hysterectomy and enlarged hysterectomy for cervical cancer. According to ACOG, the upper limit of the size of the uterus is indicated to be extracted via the vaginal route is corresponding to a load of 12 weeks, which corresponds to a weight of about 280 g. While some authors such as Donald- Fothergill, Manchester (quote,11,13), are still using vaginal surgery procedures which involve saving the uterus, most of the authors prefer radical surgeries, removing the uterus in order to avoid post operatory relapses, or the risk of the onset of benign or malignant tumors on the remaining uterus (3,7). Kovac (13), one of the best specialists in vaginal surgery, has dedicated a great part of his career in redefining the indications of vaginal hysterectomy from modern perspectives; he knocks down, step by step, based on scientific evidence of wide personal series, most of traditional contraindications. 584

5 Implications of hysterectomy on vaginal route in gynecologic pathology Lamman and Krige (quote 13) take uterus removal on vaginal route as a major indication. In 1984, Guillemin and Cavalhier (5, 12) proposed vaginal hysterectomy as an optimal treatment method. Vaginal surgery can be performed with multiple anesthesia methods, the choice of the type of anesthesia depending on the anesthesiologist s preference and the anesthetic risk. Post operatory infection in total hysterectomy has a low incidence as a result of intra operatory prevention with antibiotics (2) Worldwide, there is an increase demand for total hysterectomy with adnexectomy, a demand that is more and more frequent in Romania as well (15). CREST study was performed, in which indications for abdominal hysterectomy were distributed as follows: uterine fibroma (40%), chronic pelvic pain and endometriosis (22%); for vaginal hysterectomy, indications were: pelvic relaxation (30%), bleeding (28%), cervical dysplasia (21%), and uterine fibroma (only 7% of the cases) (9). Another national study was carried out is VALUE, which describes the hysterectomies performed in Great Britain for 2 years (1994 and 1995), and which finds that the most frequent indication for hysterectomy is dysfunctional uterine bleeding (46%), followed by prolapse (19.79%), uterine fibroma (18.51%), endometriosis (7%), pelvic masses (4.23%), and other indications (4.47%) (16). Querleu (9) believes that mobilization of the bladder is difficult in patients with C-section antecedents, regardless of the hysterectomy route and believes that C- section antecedents are not a contraindication for vaginal approach. Although the VH is a routine surgical intervention, its costs and morbidity have a significant economic impact on health and social systems. CONCLUSIONS Our evaluations brought new evidence in supporting the vaginal hysterectomy with uterus removal in a short period of time, with minimal impact on the patient, with indication in benign tumoral pathology of the uterus, among which uterine fibromatosis associated with metrorrhagia, fibromatous uterus with cervical dysplasia, or fibromatous uterus associated with different degrees of uterine prolapse; it is a technique which uses a natural route, has a limited invasion and allows a rapid recovery of the patients. In all cases, we took into consideration the onset of surgical menopause, which asks for prevention of emotional and sexual disorders, as well as disorders of other functions. REFERENCES 1. Brătilă P.C., Histerectomie vaginală, Dobrogea Publishig, Constanța, Ootaki C, Barsoum S., A day in the busy obstetric unit from the anesthesiologist point of view, experience at the Cleveland clinic; Cleveland, Ohio Masui 2009; 58(10): Nieboer, T, et al., Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews, Silver RM, Major H., Maternal coagulation disorders and postpartum hemorrhage. Clin Obstet Gynecol 2010; 53(1): Leung F, Terzibachian JJ, Gay C, Chung Fat B, Aouar Z, Lassabe C, et al., Hysterectomies performed for presumed leiomyomas: should the fear of leiomyosarcoma make us apprehend non laparotomic surgical routes? Gynecol Obstet Fertil 2009; 37(2):

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