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OBJECTIVE: This study was undertaken to determine if the use of formal guidelines in selecting the route of hysterectomy would improve medical and economic outcomes. METHOD: Data from 4595 hysterectomies performed at a single center in women whose primary diagnosis were unrelated to invasive cancer or pregnancy were analyzed in terms of mean, uterine weight, costs, length of stay, and complications. RESULTS: When formal guidelines were used to determine the route of hysterectomy, vaginal hysterectomy was performed in 90% of the patients treated and in 100% of the patients in whom the pathology was confined to the uterus. In comparison, when formal guidelines were not incorporated in the decision-making process, vaginal hysterectomy was performed in 42% of the patients treated and in 64% of the patients in whom the pathology was confined to the uterus. CONCLUSIONS: Using these or similar guidelines to assist in clinical decision making would have resulted in a potential savings of US$1184000 for every 1000 hysterectomies performed at the institution where this study was undertaken and would have freed up 1020 patient-bed days and reduced complications by approximately 20%.

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OBJECTIVE: To investigate the cost advantages and complication rates associated with surgical routes of uncomplicated hysterectomies in which uteri weigh less than 280 g and benign diseases are confined to the uterus. METHODS: Data were collected prospectively from 1988 to 1993 from 4609 consecutive women who had hysterectomies at a single institution. Women who had abdominal hysterectomies, laparoscopically assisted vaginal hysterectomies, or vaginal hysterectomies were selected if they had benign diseases confined to the uterus (adenomyosis, leiomyomas, abnormal uterine bleeding, cervical carcinoma in situ, and prolapse) and uterine weights less than 280 g. We compared length of stay, hospital charges, and associated complications between groups. RESULTS: A total of 1427 women met the study criteria. Length of stay was longer after abdominal hysterectomies than laparoscopically assisted vaginal hysterectomies or vaginal hysterectomies (3.99 +/- 1.16 days, 2.45 +/- 1.58 days, and 2.76 +/- 0.94 days, respectively; P <.001). Hospital charges for vaginal hysterectomies were significantly lower than for either abdominal or laparoscopically assisted vaginal hysterectomies (P <.001). The median charge for vaginal hysterectomies was $4166; the median charges for laparoscopically assisted vaginal hysterectomies and abdominal hysterectomies were 71% and 35% higher than this, respectively. There was a higher risk of one or more complications after abdominal hysterectomies (9.3%) than after laparoscopically assisted vaginal hysterectomies (3.6%; P <.001) or vaginal hysterectomies (5.3%; P <.001). The incidence of postoperative infection or fever was higher after abdominal than after vaginal hysterectomies (4.0% versus 0.8%; P =.029). CONCLUSION: This study supports the vaginal route of hysterectomy when disease is confined to the uterus and uterine weight is less than 280 g.

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OBJECTIVE: This study compared 3 surgical methods of prophylaxis against enterocele formation employed at the time of vaginal hysterectomy. STUDY DESIGN: One hundred consecutive women undergoing total vaginal hysterectomy for various reasons were randomly assigned to have 1 of 3 surgical methods applied to the posterior superior aspect of the vagina for prophylaxis against enterocele formation. The first procedure involved closing the cul-de-sac and bringing the uterosacral-cardinal complex together in the midline in a vaginal Moschcowitz-type operation. The second procedure was a McCall-type culdeplasty to obliterate the cul-de-sac, plicate the uterosacral-cardinal complex, and elevate any redundant posterior vaginal apex. The third technique used only the peritoneum to close the cul-de-sac, allowing passive movement of the uterosacral-cardinal complex to the midline, no obliteration per se, and no elevation of the posterior vagina. Postoperative findings on pelvic examination were evaluated at 6 weeks, 3 months, and 1, 2, and 3 years. Statistical analysis was performed with the chi2 test of independence. RESULTS: At 6 weeks' follow-up and at 3 months' follow-up there were no prolapses involving the posterior superior segment of the vagina. At 1 year of follow-up 11 patients had stage 1 or 2 posterior superior segment prolapse. At 2 years' follow-up this number was 16. At 3 years' follow-up the McCall-type method was statistically better (chi2 = 11.27 with 2 degrees of freedom, P =. 004) than the other 2 in preventing postoperative enterocele (n = 2 of 32 with McCall-type procedure, n = 10 of 33 with vaginal Moschcowitz-type procedure, and n = 13 of 33 with peritoneal closure only). CONCLUSION: When applied at the time of vaginal hysterectomy the McCall-type culdeplasty is superior to a vaginal Moschcowitz-type procedure and to simple peritoneal closure in preventing subsequent enterocele.

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The controversy continues over the appropriate use of vaginal hysterectomy for many indications that were previously treated only with abdominal or laparoscopic methods. Current outcomes data have pointed up the need for established guidelines to ensure that patients receive appropriate surgical treatment that is most cost-effective and that meets the standard of quality care. Dr Kovac reviews recent data regarding the various surgical options for hysterectomy and offers guidelines based on objective pathologic criteria.

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OBJECTIVE: This clinical study examines and defines the functional anatomy of the urethra as it relates to the Valsalva and Kegel maneuvers and to urethral stability. STUDY DESIGN: Dissection of embalmed cadavers and examination of 60 patients were performed to study adjunct structures in urethral stability. Provocative maneuvers (Valsalva and Kegel) were used in all 60 patients. Urethral prolapse was graded with use of the international Continence-Society classification. RESULTS: Cadaveric dissection confirmed the structural anatomy of the pubourethral muscles and ligaments. Physical examination in 30 patients revealed a lack of urethral stability in all patients with stress urinary incontinence. In 30 patients acting as normal controls, no urinary incontinence was present, and all maintained urethral stability with provocation. The urethrovesical junction was mobile in all patients in performing a Valsalva maneuver. CONCLUSION: Intact pubourethral ligamentous and muscular attachments aid in stabilizing the urethra to its normal anatomic position. This helps maintain continence.

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A suburethral sling anchored to the posterior-inferior aspect of the pubic bone with bone screws placed transvaginally is described for recurrent urinary incontinence. The technique involves placing a suburethral patch of a synthetic fiber at the junction of the upper one-third and lower two-thirds of the urethra and securing it by titanium bone screws to the posterior-inferior pubis for site-specific urethral support and stabilization of normally positioned continence anatomy. The procedure was performed from August 1990 through December 1991 in 27 patients with recurrent stress urinary incontinence after previous urinary incontinence surgery, of whom 25 patients were followed yearly until August 1994. None of these 25 patients have had a recurrence as of August 1996. The initial success of the pubic bone suburethral stabilization sling merits further study for the cure of urinary incontinence in patients with a hypermobile urethra or low-pressure urethral conditions.

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Hysterectomy is the most common non-pregnancy-related surgical procedure performed in the USA. The ratio of abdominal operations to vaginal operations is 3:1, which probably reflects surgeon's experience and practice styles, the absence of clear guidelines for selecting a surgical route, lack of patient knowledge about the options, and inappropriate decision-making. With the trend toward evidence-based and outcome-based practice, the indications and contraindications for abdominal, vaginal, and laparoscopically-assisted hysterectomy must be examined critically. In the author's extensive experience the rates of abdominal, vaginal, and laparoscopically-assisted procedures are 1.9, 88.7, and 9.4%, respectively. Techniques useful in vaginal hysterectomy with or without simultaneous oophorectomy, the pros and cons of simultaneous incidental appendectomy, and methods of protecting the ureter are discussed.

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OBJECTIVES: Our purpose was to determine whether there is adequate visibility and access for transvaginal oophorectomy in most patients and the success rate of the transvaginal approach. The final goal was to establish objective guidelines for choosing the route of oophorectomy with hysterectomy. STUDY DESIGN: Patients underwent laparoscopy-assisted vaginal hysterectomy (n = 91) or vaginal hysterectomy (n = 875). Ovarian removal, either unilateral (n = 97) or bilateral (n = 187), was carried out for clinical or prophylactic reasons. The accessibility of the ovaries for transvaginal removal was assessed by stretching the infundibulopelvic ligament and grading the position of the ovaries from 0 (no descent) to III (descent past the hymenal ring with traction). RESULTS: In 158 patients transvaginal bilateral oophorectomy was performed without laparoscopic assistance. In another 29 patients bilateral transvaginal oophorectomy was performed with laparoscopy-assisted vaginal hysterectomy, and prophylactic bilateral oophorectomy by the transvaginal route was successful in all but 1 of 143 patients with ovaries of grade I or higher. In 20 patients laparoscopic lysis of adhesions was necessary to permit transvaginal oophorectomy. Ninety-seven patients underwent transvaginal unilateral oophorectomy, 74 with conventional vaginal hysterectomy and 23 with laparoscopy-assisted vaginal hysterectomy. Among the patients not having oophorectomy, all ovaries had sufficient mobility to have been removed transvaginally. CONCLUSION: Good surgical practice dictates that visibility and accessibility be the primary criteria for selecting the route of oophorectomy with hysterectomy. In most patients the ovaries are visible and accessible to transvaginal removal.

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OBJECTIVE: The purpose of our study was to evaluate a surgical technique we have developed that, when used at vaginal hysterectomy, helps prevent posthysterectomy anterior vaginal segment (wall) prolapse. STUDY DESIGN: This modified surgical procedure was used in 966 consecutive vaginal hysterectomies performed from January 1989 through December 1994. Patients returned at 1, 3, and 12 months and annually thereafter for follow-up. The longest follow-up period to date is 5.5 years. RESULTS: Of the 925 patients in our study followed up for > or = 1 year, 908 (98.1%) retained excellent anterior vaginal support. Symptomatic anterior vaginal segment prolapse occurred in 12 patients (1.3%), and asymptomatic prolapse, with the anterior vaginal wall descending less than halfway from the ischial spines to the hymen, occurred in 5 (0.5%). None of the 42 patients followed up for <1 year has had evidence of prolapse. CONCLUSION: This procedure is an acceptable method to help prevent posthysterectomy anterior vaginal segment prolapse.

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OBJECTIVE: To 1) test the validity of a method of assigning patients prospectively to a vaginal, abdominal, or laparoscopy-assisted vaginal approach to hysterectomy for benign disease; 2) compare the outcomes of these options from the day of surgery to the first day of returning to normal activities; and 3) estimate the proportion of hysterectomies by each route when patients were assigned according to this system, and the impact on hospital charges. METHODS: Six hundred seventeen women were assigned to a route of hysterectomy on the basis of uterine size (greater or less than 280 g), presumptive risk factors, and uterine or adnexal immobility or inaccessibility. Data regarding the success of the procedure, complications, length of hospital stay and convalescence, and hospital charges were compiled. RESULTS: Vaginal hysterectomy alone (n = 548) or in conjunction with laparoscopy (n = 63) was successful in 99.5% of women assigned to these groups. Patients in whom the vaginal route was successful included 94% of those with uterine weights exceeding 280 g and 97% of those having risk factors often cited as reasons for selecting abdominal hysterectomy. Laparoscopic surgery was necessary to permit a transvaginal operation in only 12 of 63 patients (19%). Use of the guidelines produced a potential savings of 615 hospital days, $1,317,434 in hospital charges, and 7250 convalescent days relative to the 3:1 ratio of abdominal to vaginal hysterectomies prevalent in the United States. CONCLUSIONS: Specific guidelines for uterine size, risk factors, and uterine and adnexal mobility and accessibility are useful in selecting the operative approach to hysterectomy and will significantly reduce the number of abdominal operations performed. Laparoscopy is valuable in properly selected patients to determine the route of hysterectomy, but the need for laparoscopic techniques to permit a vaginal operation may be considerably less than some investigators have proposed.

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OBJECTIVE: We sought to determine whether sacrospinous uterosacral ligament fixation restores the uterus to its normal anatomic position, preserving uterine function and allowing future childbearing. STUDY DESIGN: This study was undertaken at two separate medical centers. Women with symptomatic uterovaginal prolapse who desired either uterine preservation or future childbearing were included. RESULTS: We successfully performed sacrospinous fixation of the uterosacral ligaments in 19 patients. Five patients have since been delivered vaginally (for a total of six deliveries). Normal anatomic restoration was accomplished in all but one patient. CONCLUSIONS: Sacrospinous uterosacral ligament fixation is an acceptable surgical means to care for symptomatic uterovaginal prolapse in women desiring uterine preservation or future childbearing. To our knowledge, this is the first report of successful pregnancies and vaginal deliveries after sacrospinous uterosacral fixation.

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OBJECTIVE: To determine the surgical anatomy of the ureter during vaginal hysterectomy. METHOD: Sixty patients undergoing vaginal hysterectomy were studied. All patients had moderate or severe uterovaginal prolapse or complete procidentia. Ureteral position was noted after traction and cutting of each uterosacral-cardinal ligament complex. RESULT: In the 40 patients with moderate or severe uterovaginal prolapse, the ureter did not move significantly when traction was applied to the cervix and there was no upward retraction on the bladder. When the uterosacral-cardinal ligament complex was cut, with forceful traction on the cervix and upward bladder retraction, the ureter was elevated from the operative field. The same was true for those 20 patients with procidentia after cutting the cardinal ligaments. CONCLUSION: Traction and cutting of the cardinal ligaments are the chief factors affecting movement of the ureter during vaginal hysterectomy; this action protects the ureter. Added protection by the cardinal ligament occurs with bladder retraction.

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To identify the effects of preoperative assessment and physician practice style on the outcomes of hysterectomy, the authors conducted a small-area analysis of 640 women under-going abdominal or vaginal hysterectomy in a St. Louis, Missouri, hospital. Of these patients, excluding outliers, 115 met the conditions for inclusion in the study. Hysterectomies were performed by the abdominal route in 55 (47.8%) and by the vaginal route in 60 (52.2%) of the 115 patients. A total of 29 physicians performed the hysterectomies. Of these 29, 15 (51.7%) were predisposed toward the abdominal approach, 13 (44.8%) had no appreciable predisposition, and one (3.5%) was predisposed toward the vaginal procedure. Path analysis revealed that physician decision making about the type of hysterectomy procedure performed was primarily influenced by practice style (predisposition) and variables related to physician preoperative assessments (uterine size and uterine mobility), some of which are prone to inaccuracy. Factors that traditionally determine operative approach (such as obesity) did not always act in the expected direction. Furthermore, the decision to perform hysterectomy vaginally had positive outcomes for both cost and length of hospital stay. Shorter hospital stays were associated with physician factors that included selection of the vaginal route, training site, predisposition toward the vaginal procedure, and preoperative assessment of uterine size. Length of hospital stay and duration of surgery were the strongest predictors of cost. Other factors being equal, the mean cost of a vaginal procedure is $224 less than that of an abdominal hysterectomy. Establishing the vaginal approach as the recommended procedure for this specific population should result in cost reductions and shorter hospital stays without negatively impacting quality of care.

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