Challenging generally accepted contraindications to vaginal hysterectomy.

OBJECTIVE: A number of preexisting clinical conditions are generally accepted as contraindications to vaginal hysterectomy. The purpose of this study was to evaluate the validity of this concept. STUDY DESIGN: The study vaginal hysterectomy group consisted of 250 consecutive patients undergoing vaginal hysterectomy. These patients (1) had a large uterus (>180 g), (2) either were nulliparous or had no previous vaginal delivery, or (3) had a previous cesarean delivery or pelvic laparotomy. Three control groups used for comparison underwent (1) laparoscopically assisted vaginal hysterectomy, (2) vaginal hysterectomy, or (3) abdominal hysterectomy. The records for all patients were analyzed for age, weight, parity, primary diagnosis, uterine size, operative time, blood loss, analgesia, hospital stay, resumption of diet, incidence of morcellation, and surgical complications. Sample size calculations were based on previous studies of complications associated with vaginal hysterectomy (alpha =.05; beta =.20). RESULTS: Hysterectomy was successfully completed by the intended vaginal route in all study patients. Major and minor complications (3.2%) were significantly less (P <.001) than in the other groups as follows: vaginal hysterectomy, 10.4%; laparoscopically assisted vaginal hysterectomy, 11.6%; and abdominal hysterectomy, 13.6%. The decrease in hematocrit was 5.7% in the study vaginal hysterectomy group compared with 6.2% for vaginal hysterectomy, 6.5% for abdominal hysterectomy (P =.009), and 6.6% for laparoscopically assisted vaginal hysterectomy (P =.002). Hospital stay was shorter for the study group (2.1 days) than for vaginal hysterectomy (2.3 days; P <.001) and abdominal hysterectomy (2.7 days; P <.001). Operative time was shorter in the study vaginal hysterectomy group (49 minutes) than with laparoscopically assisted vaginal hysterectomy (76 minutes; P <.001) or abdominal hysterectomy (61 minutes; P <.001), although morcellation was carried out more frequently in the study group (34%) than with vaginal hysterectomy (4%) or laparoscopically assisted vaginal hysterectomy (11%). CONCLUSION: Our data indicate that a large uterus, nulliparity, previous cesarean delivery, and pelvic laparotomy rarely constitute contraindications to vaginal hysterectomy.

The role of vaginal apex excision in the management of persistent posthysterectomy dyspareunia.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of vaginal apex excision in the treatment of patients with posthysterectomy dyspareunia. STUDY DESIGN: This was a case series with an independent third-party survey of patients with posthysterectomy dyspareunia managed at the University of Utah Pelvic Pain Clinic. Thirteen patients were first treated with local injections of anesthetics into localized vaginal pain foci. Further evaluation included formal psychometric testing and a diagnostic spinal block. Nine patients underwent surgical excision of the vaginal apex. An independent interviewer who did not know the patients assessed the effects of this procedure on dyspareunia and coital frequency at a mean of 36.4 +/- 3.7 months after the operation. RESULTS: The mean coital verbal analog pain score (1-10 scale) decreased from 9.22 +/- 0.27 before excision of the vaginal apex to 3.11 +/- 0.84 after the operation (P <.001), and coital frequency improved from 5.22 +/- 2.02 episodes per month before surgery to 11.11 +/- 1.82 episodes per month after surgery (P =.02). Of the 9 patients, 5 essentially had the dyspareunia cured. Dyspareunia was decreased and coital frequency was markedly increased in all but 1 of the other 4 cases. CONCLUSION: Excision of the vaginal apex is an effective treatment for carefully selected patients with posthysterectomy dyspareunia.

Dyspareunia and recurrent stress urinary incontinence after laparoscopic colposuspension with mesh and staples. A case report.

BACKGROUND: A laparoscopic colposuspension technique using hernia staples and polypropylene mesh has been introduced for the treatment of stress urinary incontinence but is not without hazards. CASE: A 32-year-old woman developed recurrent stress urinary incontinence and dyspareunia approximately one year after undergoing laparoscopic colposuspension with hernia staples and polypropylene mesh. Metal staples palpated vaginally corresponded with the area of maximal tenderness, and the bladder neck was hypermobile. Upon surgical exploration of the space of Retzius, four staples were found in the bladder wall, and polypropylene mesh densely adherent to the bladder wall had eroded into the muscularis. CONCLUSION: Laparoscopic colposuspension with hernia staples and polypropylene mesh may be associated with early recurrence of incontinence and dyspareunia.

Comparison of laparoscopically assisted vaginal hysterectomy with abdominal and vaginal hysterectomy.

OBJECTIVE: To define the advantages and disadvantages of laparoscopically assisted vaginal hysterectomy (LAVH). STUDY DESIGN: The first 70 cases of LAVH performed in a community hospital were compared with 70 cases of abdominal and 70 cases of vaginal hysterectomy performed by the same physicians during the same period. RESULTS: The mean operating time was 80 minutes for LAVH, 50 for abdominal hysterectomy and 40 for vaginal hysterectomy. The incidence of complications was low for all groups. Although the total mean hospital charges were higher with LAVH, those patients required the least postoperative analgesia, resumed a regular diet earlier, required the shortest hospital stay, and returned to regular activity and work earlier than the other two groups. CONCLUSION: LAVH offers specific benefits for properly selected patients.

Medical therapy for recurring catamenial pneumothorax following pleurodesis.

BACKGROUND: Catamenial pneumothorax, a rare complication of systemic endometriosis, has been difficult to treat successfully. Successful medical therapy is associated with amenorrhea. CASE: A 44-year-old white woman with recurring catamenial pneumothorax underwent thoracotomy and abrasive pleurodesis. Following the procedures, pneumothorax occurred again and she was treated with the GnRH analogue leuprolide acetate, 3.75 mg monthly intramuscularly. After 6 months, her therapy was changed to continuous hormonal suppression with norethindrone, 0.7 mg/day. After 6 months of this therapy and into the third episode of vaginal bleeding, the patient had another recurrent pneumothorax. CONCLUSION: Leuprolide acetate followed by continuous hormonal suppression with norethindrone was successful for 1 year in resolving recurring postsurgical catamenial pneumothorax, but the problem recurred with the resumption of vaginal bleeding during progestin therapy. Successful medical therapy requires amenorrhea.