[Hysterectomy for a benign lesion: can the vaginal route be used in all cases?]. / Hystérectomie pour lésion bénigne: peut-on tout faire par voie vaginale?

ABSTRACT

OBJECTIVE: To determine which factors indicate the vaginal route cannot be used for hysterectomy and study the morbidity of this technique in comparison with the abdominal route. METHODS: A retrospective study was conducted in 682 patients who underwent hysterectomy for benign lesions between 1992 and 1996. Genital prolapses and/or urinary incontinence accounted for 31% of the indications. Mean patient age was 50 years. There were 75 nulliparous patients and 27% of all patients had a pelvic history (including cesarean section) which might compromise vaginal hysterectomy. RESULTS: Hysterectomy was performed via the abdominal route in 39.7% of the cases and via the vaginal route in 60.3% including 5.7% with laparoscopic assistance. Factors which dictated the abdominal route were large size of the uterus (47%), pelvic background (30%), tubo-ovarian pathology (6%), multiple elements (6%), unknown (11%). Operation time depended on the surgical route, parity, pelvic background and associated techniques (prolapse, oophorosalpingectomy, uterine segmentation). Morbidity was very low and the same for both routes 1.8% operative accidents (mainly bladder wounds), 1% reoperation, only one case of thromboembolism and less than 0.5% postoperative fever. DISCUSSION: There is no absolute contraindication to vaginal hysterectomy. It would appear unreasonable to an unexperienced surgeon to use the vaginal route for a fixed uterus with an estimated weight over 400 g in nulliparous patients with a pelvic background. In a department with vaginal training, 84% of all hysterectomies could be performed by vaginal route, because half of the indications for the abdominal route are excessive or a matter for laparoscopic assistance.