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Comparison of Vaginal Hysterectomy Techniques and Interventions for Benign Indications: A Systematic Review

Barriers to performing a vaginal hysterectomy (VH) include potential complications, technical difficulties, lack of experience, and low-volume caseload. Increased knowledge is needed about factors associated with success and failure of a vaginal approach. There are no published clinical practice guidelines to direct surgeons on how to perform a VH. This systematic review was conducted by the Society of Gynecologic Surgeons Systematic Review Group to create an evidence-based clinical practice guideline addressing the relative risks and benefits of available preoperative, intraoperative, and postoperative technical steps and interventions at the time of VH for benign indications. A search of the literature was performed to identify relevant studies that compared technical steps or interventions during the preoperative, intraoperative, and postoperative periods surrounding a VH. Databases of MEDLINE, Cochrane Central Register of Controlled Trials, Health Technology Assessments, and ClinicalTrials.gov were searched from their inception until April 10, 2016, to identify all studies published in English. Studies related to the MeSH term “hysterectomy, vaginal” and associated text words were included. The search was limited to comparative studies, systematic reviews, and singlegroup studies. A total of 4250 abstracts were double screened; among these, 60 eligible studies meeting study criteria were identified; a third reviewer adjudicated discrepancies. Only 16 perioperative risks, technical steps, and interventions were identified because of limited literature. These included the following: obesity, enlarged uteri, prior surgery, use of gonadotropinreleasing hormone agonists, vaginal antisepsis, bilateral salpingo-oophorectomy, apical closure, morcellation, uterine sealers, hot cone, hemostatic injectants, retractor, cystoscopy, vaginal packing, bladder management, and accustimulation. These were organized and reported as 4 domains: patient selection, preoperative, intraoperative, and postoperative. No patient characteristics were identified that precluded using a vaginal approach. Health, Inc. All rights reserved. 534 Obstetrical and Gynecological Survey Preoperative use of chlorhexidine or povidone is appropriate for vaginal antisepsis, and injecting vasopressin intracervically at the start of VH decreases blood loss by 130 mL. Intraoperative use of tissue-sealing devices decreases blood loss by 44 mL and operative time by 15 minutes, but has unclear risks of complications. Six weeks after surgery, vertical cuff closure results in 1-cm longer vaginal length compared with horizontal closure. Postoperative use of either peritoneum or epithelium can be used for colpotomy closure; routine vaginal packing is not recommended. All available information is presented in this review. There are only minimal data to guide surgeons for planning and performing a VH. Gaps in the evidence are highlighted, and areas for future areas for investigation are identified. Surgeon experience, standard medical management, and surgical techniques from broad medical literature should be used by surgeons for decision making in areas not well addressed by this review.