Vaginal route: A gynaecological route for much more than hysterectomy

Vaginal ultrasound-guided Pouch of Douglas robotic entry in a live ovine model and human female cadaveric specimens

We aimed to determine whether intraoperative ultrasound is a feasible tool for visualization of the pouch of Douglas (POD) to facilitate a safe vaginal entry for direct robotic vaginal trocar insertion for pelvic floor surgery. Endovaginal ultrasound-guided needle insertion of a trocar into the POD was performed in six fresh frozen female cadavers and a live sheep animal model. Using an endovaginal probe the POD was identified as a fluid-filled space clear of bowel or adhesions, then a Veress needle was also used to confirm POD localization. Access to the POD was achieved using a robotic trocar designed for this purpose. The animal study was approved by the Ethics Committee of Asaf-Harofe hospital. Direct visualization during laparoscopy in cadavers and open cadaveric dissections confirmed safe POD entry and accurate trocar placement. This method was found feasible in the development of a safe vaginal entry in both the animal and cadaveric model, possibly negating the need for laparoscopic umbilical observation.

Hysterectomy with Bilateral Salpingo-Oophorectomy in Female-to-Male Gender Affirmation Surgery: Comparison of Two Methods

Introduction

The optimal route for hysterectomy with bilateral salpingo-oophorectomy in female-to-male gender affirmation surgery is still under debate, due to the quite limited and inconsistent published data. The aim of this study is to present and compare the results of vaginal and laparoscopic hysterectomy as part of gender affirmation surgery in female-to-male transsexuals.

Materials and Methods

Between 2012 and 2017, 124 female-to-male transsexuals, aged 18-43 years (mean age: 28.5), underwent hysterectomy with bilateral salpingo-oophorectomy, followed by colpocleisis and gender affirmation surgery. Transvaginal and laparoscopic hysterectomy were performed in 92 and 32 patients, respectively. Standard outcome measures (types and rates of complications, operative time, blood loss, and postoperative hospital stay) were used to compare the two groups of patients.

Results

The mean follow-up was 41 months (ranged from 6 to 65 months). The duration of transvaginal approach was significantly shorter (51 minutes compared to 76 minutes, p < 0.001). The total complication rates (less than 3%), reoperation rates (0%), blood loss, and postoperative hospital stays (4.3 days compared to 4.5 days) showed no statistical difference.

Conclusions

Both approaches are safe, with minimal complications. However, we prefer transvaginal hysterectomy due to its shorter operative time, cost-effectiveness, and simpler continuation with one-stage female-to-male gender affirmation surgery.

Cholecystectomy and Hysterectomy: A Least Invasive Approach

OBJECTIVE

The study is to promote the least invasive approach that combines cholecystectomy and hysterectomy at the same operative sitting so as to provide maximum benefits to women.

METHOD

A series of 45 women between 40 and 75 years age from year 2001 to 2014 from the private practice of author and colleague surgeons in Mumbai were in need of hysterectomy as well as cholecystectomy for gynecological indication and symptomatic gallstones, respectively. Cholecystectomy was performed laparoscopically by general surgeon and was combined with hysterectomy with or without bilateral salpingo-oophorectomy (BSO) via vaginal route by gynecologist.

RESULT

The average surgical time was 40 min for laparoscopic cholecystectomy and 32 min for hysterectomy and 40 min for hysterectomy with bilateral salpingo-oophorectomy to 64 min when uteri needed heavy debulking. Total blood loss was approximately less than 50-100 ml for hysterectomy and up to 250 ml for hysterectomy needing fair amount of debulking. Blood loss for laparoscopic cholecystectomy was 10 ml to maximum of 80 ml.

CONCLUSION

Lesson for both, gynecologists and the surgeons, is to combine these two when required and possible. This provides maximum advantages through minimizing risk of anesthesia and time duration, hospital stay, cost-effectiveness.

[Repair of post-hysterectomy vesicovaginal fistulae: the state of the art]

In western countries, vesicovaginal fistulae (VVF) are mostly iatrogenic and in the majority of cases are secondary to hysterectomy. The golden standard for the treatment of VVF has remained largely unchanged since 1953 (Couvelaire): good visualization, good dissection, good approximation of the margins, and good urine drainage. However, several aspects are still being debated, including whether or not to pursue conservative repair, the timing for surgical repair, whether to perform excision of the fistula tract, the best type of surgical access, and whether or not to use tissue interposition. We decided to review the state of the art in the treatment of VVF, which are exclusively of a traumatic nature and non-radiated, by performing a bibliography search carried on Pubmed using keywords such as "vesicovaginal fistula". The search focused on recent articles and was largely restricted to the past 10 years.

Deciding the route for hysterectomy: Indian triage system

OBJECTIVES

To review the limitations, major complications, and conversion rates associated with non-descent vaginal hysterectomy (NDVH); and develop a scoring system to predict the possibility of successful NDVH.

METHODS

The risk analysis of conversion rates from vaginal to abdominal route while attempting NDVH was applied to formulate a scoring system for the assessment of successful NDVH. Parameters were selected based on Kovacs guidelines to determine the route of hysterectomy.

RESULTS

From April 2005 to December 2008, NDVH was attempted in 364/1,378 women undergoing hysterectomy for benign conditions (Gp-I). Eight out of 364 cases (2.1 %) either had to be converted to the abdominal route or had major complication. Endometriosis and repeated sections had the highest risk. Scoring system was developed based on the risk analysis. Validity of this scoring system was tested in 1,177 women from January 2009 to September 2012 (Gp-II). 460 women with a score of 16 or less underwent NDVH successfully with a conversion rate of 0.2 %.

CONCLUSION

Careful assessment by a simple scoring system can help in deciding the feasibility of performing NDVH.

Sexual function after vaginal and abdominal fistula repair

OBJECTIVE

The purpose of this study was to compare clinical outcomes and sexual function between transvaginal and transabdominal repairs of vesicovaginal fistulae (VVF).

STUDY DESIGN

Participants (99 women with VVF at a tertiary referral center) were treated with urinary catheterization for 12 weeks and, if the procedure was unsuccessful, underwent repair using either the transvaginal (Latzko) or transabdominal technique. Objective clinical parameters were analyzed; subjective outcomes were recorded prospectively before surgery and at the 6-month follow-up examination with the use of the female sexual function index to evaluate sexual function and the visual analog scale to measure general disturbance by the fistula.

RESULTS

After bladder drainage for 12 weeks, 8 patients had spontaneous fistula closure. Demographic variables were similar in the transvaginal (n = 60) and transabdominal (n = 31) repair groups. The transvaginal procedure showed significantly shorter operation times, less blood loss, and shorter hospital stay. Continence rates 6 months after surgery were 82% (transvaginal) and 90% (transabdominal). Sexual function in the 64 sexually active patients was significantly improved, and overall disturbance by the fistula was reduced with both operative techniques. Neither surgical intervention was superior to the other regarding sexual function or visual analog scale.

CONCLUSION

Fistula repair improves sexual function and quality of life with no difference attributable to surgical route. Given this and that operating time, blood loss and length of stay are less with the transvaginal approach, the transvaginal approach is preferred in VVF repair if fistula and patient characteristics are suitable.

Constructing predictive models for vaginal surgery in patients with noninvasive gynecological conditions

OBJECTIVE

To develop predictive models for vaginal operative route selection based on clinical variables that can be easily assessed preoperatively in patients with noninvasive gynecological conditions.

DESIGN

Retrospective study.

SETTING

University Hospital.

POPULATION

Women with routine gynecological surgeries via different approaches.

METHODS

The medical records of 315 women without prolapse and undergoing hysterectomy, adnexal cystectomy or myomectomy were reviewed. Multiple logistic regression analysis was used to identify factors associated with the vaginal approach for each procedure. Predictive models were generated and optimal cut-off points were identified using the receiver operating characteristic curve.

MAIN OUTCOME MEASURES

Predictive models for different vaginal surgical procedures.

RESULTS

For hysterectomy, the patient's body mass index, dysmenorrheal complaints and uterine size were identified as negative predictors for vaginal hysterectomy, whereas previous vaginal delivery was positive. For adnexal cystectomy, adnexal pathology was a negative predictor, whereas previous vaginal delivery and ovarian cyst size were positive. For myomectomy, the body mass index and number of fibroids were negative predictors while previous vaginal delivery was positive. All three models were able to predict the vaginal procedures undergone by women and the areas under the curve were 0.88, 0.95 and 0.92, respectively. Each optimal model cut-off value (logit(p) = 0.53, 0.36, 0.73) resulted in good sensitivity (92.3%, 100% and 87.5%, respectively) and specificity (77.8%, 88.6% and 90.9%, respectively).

CONCLUSION

These predictive models, which used clinical variables that can be easily assessed preoperatively, may help surgeons to select candidates for different vaginal procedures.

Predicting the success of vaginal surgery: a quantitative risk assessment model for future investigation

OBJECTIVE

To introduce a model incorporating expected risks for a vaginal procedure based on objective measurements of a patient's characteristics and propose it as a potential tool to assist in the selection of candidates for vaginal surgery.

STUDY DESIGN

A quantitative model consisting of 13 clinical variables identified as risk factors in a prospective vaginal procedure was developed. Medical records of 315 women undergoing a set of routine gynecological surgeries via the vaginal, laparoscopic, and abdominal routes were obtained during January 2010 and November 2011. These surgeries included hysterectomy, myomectomy, bilateral or unilateral salpingo-oophorectomy and adnexal cystectomy. After that, each patient was scored according to the model. Sensitivity and specificity of the model were analyzed in one data set (cohort I) by receiver operating characteristic (ROC) curve and independently validated in a second data set (cohort II).

RESULTS

175 patients were included in cohort I while the other 140 patients formed cohort II. The intra- and post-operative complication rates were 0.6% and 0%, respectively. A vaginal procedure was predicted with good accuracy (AUC=0.852). The sensitivity was 86.0% and specificity was 72.0% at an optimal cut-off point of score=3. The predication accuracy of this model was further validated in cohort II and reached as high as 85.7%. Furthermore, the score was significantly associated with the volume of estimated blood loss and the duration of operation time (P<0.05).

CONCLUSION

Our quantitative risk assessment model predicts safe vaginal surgery with good accuracy. Predictive tools based on such a model could help surgeons to optimize patient selection and thus contribute to reducing costs while enhancing patients' satisfaction. We invite other researchers to modify and validate the model in other populations.

Vaginal hysterectomy in women with a history of 2 or more cesarean deliveries

OBJECTIVE

To perform vaginal hysterectomy (VH) safely in women with a history of 2 or more cesarean deliveries (CDs).

METHODS

A 4-step method was followed to safeguard the bladder, access the vesicouterine peritoneum (VUP), and perform VH in 312 patients with a history of 2 or more CDs. If access to the VUP did not occur at the end of step 2, step 3 and, if necessary, step 4 were implemented.

RESULTS

Hysterectomy was performed vaginally in 311 patients, and the abdominal route was resorted to in 1 patient because of hemorrhage. Only 1 patient incurred bladder trauma, which was promptly repaired.

CONCLUSION

In the absence of contraindications, the 4-step VH method described and the surgical techniques involved are safe to implement in women with a history of 2 or more CDs who need a hysterectomy.