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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 243-245

Natural orifice vaginal hysterectomy for very large-size uterus


Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission20-Jun-2021
Date of Decision16-Aug-2021
Date of Acceptance08-Sep-2021
Date of Web Publication19-Nov-2021

Correspondence Address:
Dr. Latika Chawla
Department of Obstetrics and Gynecology, Level 6, Academic Block, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_58_21

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How to cite this article:
Prateek S, Chawla L, Yadav A, Sharma S. Natural orifice vaginal hysterectomy for very large-size uterus. J Med Evid 2021;2:243-5

How to cite this URL:
Prateek S, Chawla L, Yadav A, Sharma S. Natural orifice vaginal hysterectomy for very large-size uterus. J Med Evid [serial online] 2021 [cited 2022 Aug 15];2:243-5. Available from: http://www.journaljme.org/text.asp?2021/2/3/243/333991




  Introduction Top


Hysterectomy is most often performed gynaecological surgery. Although laparoscopy and robotic-assisted procedures are gaining rapid popularity, evidence still supports non-descent vaginal hysterectomy (NDVH) as a first-line approach wherever possible.[1],[2] NDVH is associated with shorter duration of hospital stay, lesser post-operative pain, faster post-operative recovery, fewer urinary tract injuries, shorter operative time[1],[2] and better quality of life post hysterectomy. Large size of uterus, pelvic adhesions and endometriosis are supposed to be few indications which favour laparoscopic or abdominal approaches. However, in this case series, we report successful removal of uterus by NDVH (which we prefer to call natural orifice vaginal hysterectomy [NOVH]) in three patients with very large-size uterus and with pelvic adhesions.


  Cases Report Top


A 46-year-old patient presented with pain lower abdomen. She had a 22–24-week period of gestation size uterus, mobile, with a 10–12 cm subserosal fibroid with intramural component on ultrasound. The patient was very keen on avoiding a scar on her abdomen. So after a detailed clinical examination, the option of NOVH was discussed with her. We administered 3 doses of GnRH agonist, Leuprolide Acetate (Sun-Pharma) 3.75 mg subcutaneously monthly for 3 months. Uterine size reduced to 18–20 weeks after which we successfully performed NOVH. The bladder was opened by sharp dissection. Uterus along with fibroid was removed by coring. Time taken surgery was 150 min and there was only 300 ml blood loss. [Figure 1]a shows hysterectomy specimen. There were no intraoperative or post-operative complications and the patient was discharged after 36 h of surgery.
Figure 1: (a) Hysterectomy specimen (18–20-week clinical size) with 8 cm subserosal fibroid with intramural component, (b) hysterectomy specimen (18–20-week clinical size) with multiple intramural, subserosal and submucosal fibroids), (c) hysterectomy specimen (18-week clinical size) with multiple intramural, submucosal and subserosal fibroids

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A 44-year-old patient with three living issues presented with lump, pain lower abdomen and heavy bleeding with periods. She had a history of previous two caesarean sections and an open myomectomy. Uterus was 20–22-week period of gestation size. Ultrasound showed one 6 cm × 6 cm subserosal fibroid with multiple small intramural and subsmucosal fibroids. We administered 3 doses of GnRH agonist, Leuprolide Acetate (Sun-Pharma) 3.75 mg subcutaneously monthly for 3 months. Uterine size reduced to 18 weeks after which we could successfully perform NOVH and avoided a fourth laparotomy. Enucleation of the myomas was done intraoperatively to debulk the uterus. Time taken surgery was 180 min and there was only 250 ml blood loss. There were no intraoperative or post-operative complications and the patient was discharged after 36 h of surgery. [Figure 1]b shows hysterectomy specimen.

A 47-year-old female was referred from a peripheral health facility in our state with a history of attempted laparotomy for fibroid uterus 8 days back for pain and lump abdomen. Surgery could not be performed due to dense adhesions in the abdomen and pelvis. On examination, there was a midline vertical scar reaching up to the umbilicus. The uterus was 24-week size, firm, with restricted mobility, bilateral fornix was blunt. Three doses of Injection Leuprolide Acetate 3.75 mg subcutaneously were given monthly. After 3 months, uterine size was reduced to 18–20-week period of gestation size. Intraoperatively adhesions in the vesico-uterine pouch were encountered. Hence, posterior pouch was opened first. Adhesions were encountered posteriorly as well. They were released with fingers dissection. Mackenrodt ligaments were clamped and cut first after pushing the bladder upwards by sharp dissection. All clamps including the uterine artery pedicles were applied very close to the uterus to avoid injury to the adjacent viscera and omentum. The posterior surface of the uterus was bifurcated simultaneously and fibroids were enucleated. After clamping cornu-fundal structures, the anterior pouch was opened by finger dissection. There were multiple intramural, submucosal and subserosal fibroids [Figure 1]c Natural orifice vaginal was successfully performed without any intraoperative or post-operative complications. Time taken surgery was 120 min and there was around 300 ml blood loss. The patient was discharged after 48 h of surgery. We avoided a repeat laparotomy which is associated with a significant risk of bladder injury and bowel injury.


  Discussion Top


American College of Obstetricians and Gynaecologists (2017) states that vaginal route for surgery should be the approach of choice whenever suitable).[3] As already mentioned, NOVH is patient-friendly, associated with less post-operative pain, less febrile morbidity, faster post-operative recovery, early mobilisation, shorter duration of hospital stay, lesser operative time and fewer urinary tract injuries. NOVH is cost-effective as it does not require expensive equipment. Interestingly, this surgery uses a natural passage for operating; therefore, there is no additional scar on the abdomen, not even the four laparoscopic port site scars on the patient's abdomen. Therefore, this approach also has a cosmetic advantage over the laparoscopic route.[1],[2],[3] Despite the above advantages, some gynaecological surgeons may not prefer NOVH due to surgeon preference for other routes (laparoscopic or robotic) that are associated with more glamour. Operating through the vagina offers less surgical space to the surgeon and thus, the novice may find this challenging as compared to laparoscopic surgery that offers a better view and plenty of space to operate. This may add to their reluctance in adopting this technique. NOVH becomes surgically even more challenging in nulliparous women (less spacious vagina), patients without previous vaginal deliveries and with history of previous caesarean section/myomectomy. Relative contraindications, even with the most experienced surgeons, include very large uteruses (more than 20-week period of gestation size), endometriosis, previous uterine surgery, restricted uterine mobility, cervix flushed with vagina and severely restricted vaginal space.

In all above three mentioned patients, very large size of the uterus (more than 20 weeks) posed a unique therapeutic challenge for us. Three doses of GnRh agonist preoperatively significantly reduced the uterine size in all cases to facilitate an attempt at NOVH. Appropriate pre-operative counselling is always done to educate patients about intraoperative conversion to laparotomy/laparoscopy which is not a complication of NOVH. The first patient had a large subserosal fibroid. The second patient had multiple fibroids with previous three laparotomies (two cesarean sections and one myomectomy). The third patient had a frozen pelvis with dense abdominopelvic adhesions with a history of previous failed attempts at abdominal hysterectomy. In all these three cases, at the initial examination, rather than planning an abdominal hysterectomy straight away, we discussed with the patient and attempted to reduce uterine size with pre-operative GnRH agonist therapy. We were successful in reducing the uterine size so as to facilitate NOVH, avoid laparotomy and morbidity associated with the above high-risk cases.

Vaginal hysterectomy is not often performed for large-size uterus.[4] As discussed till now, very large-size uterus is considered as a relative contraindication to NOVH. A recent Indian study[5] concluded that NDVH is a cost-effective and safe approach of hysterectomy for women with large-size uteri. They included 65 cases with large-size uterus (>12 weeks in size) with 7 patients having uterine size more than 18 weeks including only 2 with very large uteri. A study by Doucette et al. successfully challenged the dogma for contraindications to NDVH.[6] This group successfully performed NDVH in 250 patients with large-size uterus (weight >180 gm) including nulliparous women and women with previous laparotomies and caesarean sections. They concluded that large size of uterus, nulliparity, previous pelvic laparotomies and caesarean section rarely constitute contraindications to vaginal hysterectomy.

With this case series, we wish to emphasise that in trained hands, NOVH can also be a safe and effective treatment strategy in women even with a very large-size uterus (more than 20-week size). However, there should be proper case selection and intense pre-operative patient counselling. For larger uterus, previous pelvic surgery, broad uterus with restricted mobility and for beginners, laparotomy should always be kept as a stand by and explained to the patient beforehand. Pre-operative therapy with agents (GnRH agonists, mifepristone) may be considered to reduce uterine volume thereby increasing success rates of NOVH. These volume-reducing agents provide valuable support in turning the table towards NOVH which is comparable to any mode of hysterectomy. In cases of larger uterus with multiple fibroids, a specimen may be delivered either by bifurcation, coring or enucleation of fibroids. Posterior pouch may be opened first in case if the vesico-uterine pouch is high up or densely adhered.

NOVH is scarless, does not require expensive equipment and can be offered as a safe and viable option for very large-size uterus in trained hands where ever possible.

Primary physicians very often attend to the complainants of gynaecological patients. This case report is of importance because it emphasises upon the primary physician (many of whom may be the first contact of the patient that may ultimately require a hysterectomy) that natural orifice hysterectomy is a safe alternative even in very large uteruses and patients should always be made aware of this least invasive route for surgery before referring to a higher centre for definitive management.

Acknowledgements

We are grateful to all patients who had faith in us, residents of Unit 3, Department of Obstetrics and Gynaecology, staff of Gynaecology ward and Gynaecology operation theatre (OT).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee SH, Oh SR, Cho YJ, Han M, Park JW, Kim SJ, et al. Comparison of vaginal hysterectomy and laparoscopic hysterectomy: A systematic review and meta-analysis. BMC Womens Health 2019;19:83.  Back to cited text no. 1
    
2.
Aarts JW, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BW, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015;2015:CD003677.  Back to cited text no. 2
    
3.
ACOG Committee Opinion No. 444: Choosing the route of hysterectomy for benign disease. Obstet Gynecol 2009;114:1156-8.  Back to cited text no. 3
    
4.
Unger JB. Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams. Am J Obstet Gynecol 1999;180:1337-44.  Back to cited text no. 4
    
5.
Rameshkumar R, Naik SN, Dhanalakshmi. Non-descent vaginal hysterectomy for large uterus – Safety and feasibility. Int J Reprod Contracept Obstet Gynecol 2018;7:3563-7.  Back to cited text no. 5
    
6.
Doucette RC, Sharp HT, Alder SC. Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol 2001;184:1386-9.  Back to cited text no. 6
    


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