A review of vaginal hysterectomies in the gynaecology department of a tertiary care hospital

This retrospective cohort study analysed the trends and complications of vaginal hysterectomy conducted at Services Hospital, Lahore, from January 1, 2015 to December 31, 2020. Demographics, indications, surgery duration, complications (haemorrhage, urological or rectal problems, infection), and hospital stay were recorded. Out of 819 hysterectomies performed for benign gynaecological conditions, 112 (13.68%) were vaginal hysterectomies. Non-descent vaginal hysterectomy (NDVH) accounted for 33(29.46%) and uterine prolapse for 79(70.53%) of the cases. Mean age was 52.35±8.74 years, parity was 5.01±1.32, intraoperative haemorrhage was 796.87±450.1 ml, surgery duration was 48.61±12.28 minutes, and hospital stay was 2.58±0.41 days. Complications occurred in 19(16.97%) of the cases, while 93(83.03%) cases had no complications. Outcomes were comparable between NDVH and vaginal hysterectomy for prolapse (p=0.552). This indicates that vaginal hysterectomy is a safe procedure with minimal complications and quick recovery for uterine prolapse and non-descent uterus. However, a declining trend was observed over the study period.


Introduction
Hysterectomy is the surgical removal of uterus and one of the most frequently performed major gynaecological surgeries.Hysterectomy can be performed through different routes such as abdominal, vaginal, or laparoscopic.
The American College of Obstetricians and Gynaecologists (ACOG) and International Society for Gynaecologic Endoscopy (ISGE) recommend vaginal hysterectomy as the first choice for benign gynaecological conditions, while laparoscopic approach should be considered when vaginal hysterectomy is contraindicated or technically impossible. 1,2aginal hysterectomy is largely under-utilised and globally the trends are decreasing.Laparoscopic hysterectomy has replaced abdominal hysterectomy in the developed world but despite having more morbidity, abdominal route is common in low-and middle-income countries (LMIC). 3,4is study was planned to evaluate the trends in vaginal hysterectomy for benign diseases over a period of six years at Services Hospital, Lahore, and to assess the safety of the procedure in terms of intraoperative and postoperative complications so that better approach can be planned.

Methods
It was a retrospective cohort study which was carried out at the Department of Gynaecology and Obstetrics, Services Hospital, Lahore, from January 2015-December 2020.Medical records of all patients who had undergone hysterectomy over this period were retrieved after approval from the ethical committee (reference No. IRB/2021/900/SIMS).The case files were reviewed and data regarding socio-demographic characteristics, indications for vaginal hysterectomy, duration of the procedure, amount of blood loss during surgery, duration of hospital stay and post-operative complications till one week, was extracted using a purpose designed proforma.Data was analysed using SPSS version 22.0.A p-value of < 0.05 was selected as test of significance.

Results
During the six-year study period, 819 hysterectomies were performed for benign gynaecological causes.Of these, 707(86.32%)were abdominal hysterectomies whereas 112 (13.68%) were vaginal hysterectomies.Average rate of vaginal hysterectomies over this period of six years was 18.67 per year.The rate of vaginal hysterectomy showed a declining trend over a period of six years as shown in Figure 1.
Mean age of the patients was 52.35±8.74years with mean  1).
There were no complications in 65(82.24%)out of 79 patients in whom vaginal hysterectomy was done for uterine prolapse and 28(84.84%)patients with NDVH (p=0.552).There were few complications which were not statistically significant in both the groups (Table 2).

Discussion
During the six-year study period, 112 (13.6%) vaginal hysterectomies were done for benign gynaecological condition.Similar numbers were seen in other studies which reported 16.5%-17.8%vaginal hysterectomies with decreasing trend over the years. 5,6A Nigerian study, conducted over a period of 14 years, reports a rate of 2.3% vaginal hysterectomy out of major gynaecological operations. 7It indicates that vaginal hysterectomy procedure rate is declining globally and abdominal approach is being preferred.Abdominal hysterectomy is easier for the surgeon due to wide exposure, but it is associated with more complications as compared with vaginal hysterectomy.Abdominal hysterectomy is associated with increased blood loss, fall in haemoglobin level, more analgesia requirement, and post-operative morbidity in terms of increased chances of wound complications, while vaginal hysterectomy has fewer complications with faster return to activity. 8e developed world has shifted towards minimally invasive surgery but it is not possible in LMICs, where resources are deficient and laparoscopic equipment is expensive, proper training is required and it is not available at public sector hospitals and at rural settings where most of the community resides.Cochrane review of 42 studies with 5,102 patients comparing various routes of hysterectomy, concluded that vaginal hysterectomy is superior to LH and abdominal hysterectomy. 9In the present study, surgery was performed due to uterine prolapse in 79(70.53%)patients, while non-descent vaginal hysterectomy was done in 33 (29.46%) patients mostly due to heavy menstrual bleeding.Uterine prolapse is the main indication for vaginal hysterectomy in various studies. 6,7There were no complications in 93 (83.03%) cases.Mean operative blood loss was 796.87±450.1 ml, while mean operative time was 48.61±12.28minutes.Mean duration of surgery as  39.6±65.2minutes has been reported by various studies with less average blood loss as compared to abdominal hysterectomy. 8,9Mean hospital stay was 2.58±0.41days in the current study.Short hospital stay with quick return to activity is possible because there is no incision, the operation is performed through natural orifice and operation time is shorter.
No cases of wound infection, bladder and ureteric injury were reported in the current study.Eight (7.14%) patients needed blood transfusion and 5 (4.4%) patients had febrile morbidity.Similar results of fewer complications are reported from other studies.Limitations of the study: It was a single centre study with estimation of short-term morbidity.There were fewer patients of NDVH.It is suggested that multi-centre studies with a large number of patients and follow-up be carried out so that greater evidence of short-and longterm morbidity can be generated for better patient care.

Conclusion
A declining trend of vaginal hysterectomy was observed during the study period.Vaginal hysterectomy is a safe option for uterine prolapse and non-descent uterus with fewer complications.

Figure :
Figure: Trend of vaginal hysterectomy over six years 3epartment of Obstetrics and Gynaecology, Services Hospital,3Department of Obstetrics & Gynecology, Sheikh Zayed hospital, Lahore.

Table - 2
: Comparison of post-operative complications in vaginal hysterectomy for prolapsed uterus versus non-descent vaginal hysterectomy.