Expert offers tips on performing transvaginal hysterectomy: how to select patients.(Gynecology)

ST. LOUIS -- Data continue to show that the transvaginal approach to hysterectomy can be safely performed in selected patients, including those with a large uterus, Dr. Octacilio Figueiredo Netto reported during the 13th International Pelvic Reconstructive and Vaginal Surgery Conference.

More than 200 studies on the vaginal approach have been published in the past few years, and the evidence from these--as well as from his own experience with 1,200 cases--is extremely strong, said Dr. Netto, who is a surgeon at Londrina (Brazil) State University.

Of the 1,200 transvaginal hysterectomies he attempted, more than 99% were completed successfully, Dr. Netto said at the meeting, noting that the complication rate was low, with fewer than 2% experiencing vaginal or rectal lacerations, and 0.5% requiring conversion to laparotomy,

Few cases required laparoscopic assistance, 65% involved morcellation of the uterus, and 75% of patients returned home the day after surgery, Dr. Netto said.

Proper patient selection is one of the keys to success with vaginal hysterectomy, The ideal patient is thin, has had a previous vaginal delivery, hasn't undergone previous pelvic surgery, and has good vaginal amplitude and normal ovaries, fallopian tubes, and adnexa.

Very few patients will fit all these criteria, but one particularly important characteristic for this approach is a mobile uterus, which should be mobile in all directions and should have slight descensus upon cervical contraction. This can be discerned during the office examination, but should also be tested just before the procedure using bimanual examination with the patient under anesthesia. The degree of uterine descensus can then be determined by pulling down on the cervix, Dr. Netto said.

"This will give you the last hint as to whether you should proceed" transvaginally, he said.