{"paper_id":"7b76d2d3-e861-4ef8-b176-aabe904e3d47","body_text":"Journal of Sylhet Women’s Medical College (JSWMC)  ISSN: 2708-2857 (P), 2710-0405 (O) \nJournal.swmc.edu.bd 2022 July; Volume 12; Issue 02 \n74 \n \n DOI: https://doi.org/10.47648/jswmc2022v12-02-55 \nPersonal experience of Non Descent Vaginal Hysterectomy (NDVH) in a \nDistrict Hospital—A Study of 60 cases. \n*Siddiqua SF1, Begum MN2 \nAbstract: \nObjective(S): To share our experience and explore the safety & feasibility of NDVH in 60 cases. \nMethods: This prospective observational study was conducted from Jan 2016 to Dec 2017 in Obstetrics \nand Gynaecology Department of Sylhet shaheed Shamsuddin Ahmed Hospital, Sylhet. Sixty patients \nrequiring hysterectomy for benign nonprolapsed gynaecological disorders were the target population. \nPrerequisite for non-descend vaginal hysterectomy were uterine size not exceeding 20 weeks, adequate \nvaginal access with uterine mobility. \nMain outcome measures were i) Procedures of removal of large uterus ii) Time taken to complete the \noperation iii) Blood loss during operation iv) Postoperative hospital stay. v) Postoperative complications. \nResults: Vaginal hysterectomy was completed successfully in 100% cases. All patients were multiparous \nand in 41-45 years age group (37%). Commonest indication was AUB (37%), Second indication was \nfibroid uterus (35%) and next indication was adenomyosis (13%). In most of the case uterus was 10-12 \nweeks size (37%), in 28% cases uterine size was less than 8 weeks, 14-16 weeks size in 27% cases and \nuterus was more than 16 weeks size in 8% cases. Morcellation techniques like bisection, myomectomy, \nwedge resection and debulking were done to remove bigger sized uterus. Mean operating time was 45 \nminutes. Mean blood loss was 60ml. Average hospital stay was 3 day. Complications were minimum which \nincluded UTI and febrile morbidity. At 12 weeks postoperative follow up 72% patient had no adverse \ncomplain though 18% cases was drop out. \nConclusions: Vaginal hysterectomy is safe feasible, scarless and patient friendly approach for benign \ngynaecological disorders other than prolapsed uterus. In this era of minimally invasive surgery, non-\ndescend vaginal hysterectomy is to be considered as a safe option. \n \nKey words: debulking, morcellation, non-descend vaginal hysterectomy. \n \nJSWMC 2022 [12(02)] P: 74-79\nIntroduction:  \nHysterectomy is one of the most commonly \nperformed major gynaecological operative \nprocedures. Traditionally various routs for \nremoval of uterus have been used like \nabdominal, vaginal, laparoscopic route and with \nrobotic assistance. Abdominal hysterectomy is \nundoubtedly the most popular with a 70:30 for \nabdominal versus vaginal route.1,2,3 \n \n1. Dr. Shah Fahmida Siddiqua, Assistant Professor, \nDept. of Obs & Gynae, MAG Osmani Medical \nCollege, Sylhet. \n2. Dr. Mosammath Nazma Begum, Junior Consultant \nObs & Gynae, Shaheed Shamsuddin Ahmed \nHospital, Sylhet. \n \nCorresponding author: Dr. Shah Fahmida Siddiqua \nMBBS, FCPS (OBGYN), MS (OBGYN) \n Assistant Professor, Dept. of Obs & Gynae,  \nMAG Osmani Medical College, Sylhet.  \nEmail: fahmidasiddiquapoppy@gmail.com \n \n \n \n \n \nSkill and experience of the surgeon play an \nimportant role in determining the route. Factors \nto be considered in safety, cost-effectiveness and \nthe medical needs of the patients.4 Superiority of \nhysterectomy by vaginal route is generally \naccepted as it a natural hiatus but still most of \nthe gynaecologists use this route only for uterine \nprolapse, preferring abdominal hysterectomy for \nother indications. Most of surgeon find it easier \nto perform abdominal hysterectomy through a \nwide-open incision and find difficulties to avoid \nvaginal route. Laparoscopic route is enjoying \nmuch popularity in these two decades. However \nlaparoscopic hysterectomy is associated with \nhigher costs, longer duration of operation, \nprolong anaesthesia, specially trained personnel, \ncostly instruments and risks related to \nlaparoscopy.5 On the other hand, non descent \nvaginal hysterectomy is associated with less \nmorbidity, lower health care costs, lesser \nhospital stay, minimal complications and better \npatient satisfaction. There is no  abdominal \n Original Article \n\nJournal of Sylhet Women’s Medical College (JSWMC)  ISSN: 2708-2857 (P), 2710-0405 (O) \nJournal.swmc.edu.bd 2022 July; Volume 12; Issue 02 \n75 \n \nincision hence cosmetically approved  by patient \nwhich allows earlier recovery and return to \nwork, compared to abdominal and laparoscopic \ntechniques.3,6 , there is a need for expanding the \nindication for the vaginal hysterectomy rather \nthan restricting it to the conventional indication \nof uterovaginal prolapse.5  Usual limitation of \nvaginal hysterectomy in non descent uterus is its \nsize but now with larger sizes, hysterectomy can \nbe facilitated by bisection, wedge bulking, \nmorcellation, myomectomy.7  There is ample \nopportunity to learn and master vaginal surgery. \nTraining and experience in vaginal surgery \nappear to be the major determinant of this type \nof hysterectomy performed.8 \nThe aim of this study is sharing experience of \nnon-descent vaginal hysterectomy and exploring \nits safety & feasibility in benign disease of non \nprolapsed uterus and maximizing the proportion \nof hysterectomy to be performed vaginally at \nSylhet Shaheed Shamsuddin Ahmed Hospital, \nSylhet. \n \nMaterial and Methods: \nThis prospective observational study was \nconducted from Jan 2016 to Dec 2017 in \nObstetrics and Gynaecology Department of \nSylhet Shaheed Shamsuddin Ahmed Hospital, \nSylhet. A total of 60 cases of benign \ngynaecological disorders who had no descent of \nuterus or vagina and needed hysterectomy were \nthe target population of this study. A preformed \nquestionnaire was made for data collection. \nSelection criteria for non descent vaginal \nhysterectomy (NDVH) were  i) Uterine size not \nexceeding 20 weeks of gravid uterus (by clinical \njudgment) ii) adequate vaginal access with good \nuterine mobility . Exclusion criteria included \nuterus with restricted mobility, suspicion of \nmalignancy and complex adnexal masses. \nConsent for conversion of procedure to \nabdominal hysterectomy (if needed) was taken.  \nA detail history from the patient was taken. A \nthorough examination was done including \ngeneral examination, per abdominal \nexamination, per vaginal examination for size \nand position of uterus, degree of descent, \nmobility, vaginal capacity & presence of \ncystocele or rectocele. \nThe patients were thoroughly investigated by \nroutine investigations eg. Complete haemogram, \nblood grouping & Rh typing, blood sugar, serum \ncreatinine, VIA test, ECG, chest X-ray, \nultrasonogram of abdomen & pelvis, HBSAg, \nurine analysis. A good bowel preparation was \ntaken in every case to gain good exposure and \navoid bowel injury. A written informed consent \nwas taken from all patients after explaining the \nprocedure. After all preparation patients were \noperated under spinal anesthesia. \nAll cases were re-assessed in operating theater \nafter the patient was anesthetized to confirm the \nsize, mobility of uterus, vaginal accessibility and \nof pelvic muscles. \n \nOperative Technique: \nDuring vaginal hysterectomy antiseptic cleaning \nand draping was done, cervix was held with long \ntissue forceps. A circular incision was given \naround the cervix. The pubo-vesico-cervical \nligament was cut, vesicocervical space exposed \nand bladder mobilized appropriately. The pouch \nof Douglas was exposed next. After that the \nMackenrodts ligament and utero sacral ligament \nwere cut and ligated then the uterine vessels \nwere cut and ligated bilaterally. In big sized \nuterus techniques like uterine bisection, \ndebulking, wedge resection, myomectomy or \ncombinations of these procedures were \nperformed when required to ease limitation of \nspace for further proceeding. Lastly the round \nligament, fallopian tube, ovarian or \ninfundibulopelvic ligament were cut and \nsutured. Finally uterus was removed. Vaginal \npack and Post-operative catheter was kept in all \ncases for 12 to 24 hours. Vaginal hysterectomy \nwas considered successful if it was not \nabandoned or converted to abdominal route. All \npatients received 3 days injectable antibiotics. \nOn 3rd postoperative day hemoglobin estimation \n& urine analysis were done. Postoperative \ncomplications like fever, urinary tract infection \nand vaginal culf cellulities were noted. All \npatients were followed from time of admission \nto time of discharge and 2 weeks and 12 weeks \nthereafter to note their well being or any late \ncomplication like vaginal discharge, \nurinary/bowel symptoms.  \nData regarding age, parity, uterine size, \nindications, estimated blood loss, length of \noperation, complications, adjuvant procedures, \nclinical outcome and postsurgical hospital stay \n\nJournal of Sylhet Women’s Medical College (JSWMC)  ISSN: 2708-2857 (P), 2710-0405 (O) \nJournal.swmc.edu.bd 2022 July; Volume 12; Issue 02 \n76 \n \nwere recorded. Operating time was calculated \nfrom the start of incision at cervico-vaginal \njunction to the placement of vaginal pack. \nEstimated blood loss was calculated by \ndeducting previously weighted gauzes and mops \nfrom bloodsoaked weighted gauzes & mops and \ntransfer the weight in milliliter (1 oz= 30ml). \nStatistical analysis was done by using \npercentage. \n \nResults: \nA total of 60 cases for different indication were \noperated by NDVH technique in our study \nperiod. Data were collected and different tables \nwere made. \n \nTable 1   Age distribution ( n = 60) \nAge \ngroup \nNumber of \nPatients \nPercentage \n(%) \n35-40 13 23 \n41-45 22 37 \n46-50 20 33 \n>50 05 8 \n \nTable I showed 37% cases were in age group 41-45, \n33% were in 46-50yrs age group, 23% patients were \nbelow 40 yrs and 8% were of above 50yrs. \n \nTable 2 Distribution of parity ( n = 60) \nParity Number of \npatients \nPercentage \n(%) \n01 02 3 \n02 07 12 \n03 15 25 \n04 15 25 \n05 14 23 \n>5 07 12 \n \nTables 2 showed most of the patients were \nmultipara, 50% had para 3 to 4 & 23% had para \n5and more. 12% had para 2 and 3% were \nprimipara.  \n \nTable 3 Co-morbidity of the patients \nMedical problem Number of \npatients \nPercentage \n(%) \nDiabetes melitus 18 30 \nHypertension 13 22 \nHypothyroidism 04 10 \nBronchial Asthma 02 3 \nDiabetes melitus \nwith Hypertension \n05 8 \nNone 18 30 \nTable 3 showed among 6 0 patient 30 % have no \nassociated co-morbidity. 30% had DM, 22% had \nHTN and 10% had hypothyroidism. \n \nTable 4 Debulking techniques used for NDVH \nTechniques Cases Percentage (%) \nBisection 24 40 \nMyomectomy 16 27 \nMorcellation 08 13 \nCombind 04 7 \nIntact uterus 08 13 \n \nTable 4 showed in 13% cases uterus was removed \nintact, in 40% patients bisection, in 27% cases \nenucleation of myoma, in 13% cases wedge \nresection and in 7% cases combination of \nprocedures required to be done as a morcellation \nprocedure to remove the uterus.  \n \nTable 5: Outcome of surgery \nOutcome of surgery Mean \nMean operating time 45 minutes \nMean blood loss 60 ml \nMean(posoperative) \nhospital stay  \n3 days \n \nTable 5 showed clinical outcome. Mean operating \ntime was 45min Operating time was directly \nrelated to the size of uterus, Mean blood loss was \n60ml. Most of the patients were discharged 3 days \nafter operation. \n \nTable 6: Surgical complications \nComplications No of \npatients \nPercentage \n(%) \nBladder injury 0 0 \nUreter injury 0 0 \nBowel injury 0 0 \nPrimary hemorrhage 0 0 \nSecondary hemorrhage 0 0 \nVault hematoma 0 0 \nPelvic abscess 0 0 \nFebrile morbidity 05 8 \nUrinary tract infection 04 7 \nConversion to \nlaparotomy \n0 0 \n \nTable 6 showed postoperative complications. \nThere was no bowel, bladder or ureteric injury. No \nmajor morbidity was observed. Febrile morbidity \nwas found in 8% cases and urinary tract infection \nwas found in 7% cases. \n\nJournal of Sylhet Women’s Medical College (JSWMC)  ISSN: 2708-2857 (P), 2710-0405 (O) \nJournal.swmc.edu.bd 2022 July; Volume 12; Issue 02 \n77 \n \nTable 7 Post Operative follow up (at 12 weeks) \nFollow up No. of \npatients \nPercentage \n(%) \nNo complain 43 72 \nPain 03 5 \nDyspareunia 02 3 \nVault granuloma 02 3 \nAbscent from \nfollow up \n10 17 \n \nTable 7 showed postoperative follow up at \n12weeks. Most of the patient had no complain \n(72%). A fairly large number of patients (17%) \nwere absent from follow up. 5% patient had \ncomplain of lower abdominal pain, 3% had \ndyspareunia and 3% developed vaginal discharge \ndue to vault granuloma. \n \nFig: I Indication for NDVH \n \nFig: I showed most common indication for NDVH \nwas abnormal uterine bleeding (37%) followed by \nfibroid uterus (35%) and 3rd most common \nindication was adenomyosis (13%). \n \nFig: II Uterine size selected for NDVH \n \n \nFig: II showed most of the cases had uterus 10-12 \nweeks and 28% had <8weeks size. 27% had uterus \n14-16 weeks size and 8% had uterus >16 weeks \nsize. \n \nDiscussion: \nThe most common route opted for hysterectomy \nis abdominal route. Thomas G Stoval et all \nfound that 70% to 80% of hysterectomies are \nperformed by abdominal route whereas vaginal \napproach is usually reserved for utero-vaginal \nprolapsed.9 Big uterus and inadequate technical \nskills make the vaginal route difficult. Good \nuterine mobility, adequate vaginal access and in \nabsence of adhesion vaginal hysterectomy even \nsalphingoophorectomy can easily be performed. \nMultiparity, lax tissue following multiple \ndeliveries and decreased tissue tensile strength \nprovide comfort to the vaginal surgeon even in \npresence of big uterus. \n \nIn our study out of 60 cases selected for NDVH, \nall cases were completed successfully. No one \nneeded conversion to abdominal hysterectomy. \nThough one study shows conversion of the \nprocedure to abdominal hysterectomy for \nvarious reasons10In this study majority of the \npatients were in the age group of 41-45 years \nand most of them were multiparous, which is \ncomparable to other studies.3,11-15 In this study \n30% of patients had Diabetes melitus, 30% was \nuncomplicated with any medical disorders, 22% \nhad hypertension and 10% had hypothyroidism. \n20% of patients in our study had history of \nprevious cesarean section,15% had history of \nbilateral tubal ligation and 12% had history of \nlaparotomy. Most common indication of NDVH \nin our study was abnormal uterine bleeding not \nresponding to medical treatment (37%) and \nsecond most common indication was fibroids \n(35%), 3rd most common indication was \nadenomyosis (13%). Shital Mehta et al, Bhadra \nB et al also reported AUB as a most common \nindication.14,16 Only NDVH was done in 81% \ncases, NDVH with pelvic floor repair was done \nin 18% of patients for associated cystocele and \nsome rectocele, salphingoophorectomy was done \nalong with NDVH in 8% cases. Benign adnexal \npathology can easily be dealt in this vaginal \nroute without any complication and \nurogynaecological surgery can also be \nperformed at the same sitting. In majority of \ncases in our study size of the uterus was 10-12 \nweeks size (37%), 28% were less than 8weeks \nsize uterus and in 27% cases uterus were 14-16 \nweeks size. Debulking was done when uterine \n\nJournal of Sylhet Women’s Medical College (JSWMC)  ISSN: 2708-2857 (P), 2710-0405 (O) \nJournal.swmc.edu.bd 2022 July; Volume 12; Issue 02 \n78 \n \nsize was more than 12 weeks. Among all of the \nlarge uterus bisection, morcellation, \nmyomectomy, wedge resection and \ncombinations remained the common technique, \nwhich was shown by other study also.17 One can \nsafely use morcellation procedure, after bilateral \nuterine vessel ligation. Now a days fibriod upto \n20 weeks size or even more and adnexal \npathology can also be removed vaginally by \nusing different morcellation techniques.20,21 \nMean time for operation in this study was 45 \nminutes. It was lesser than that reported in other \nstudies, Arifa A Zahan et al (50.5 min)22, Goel et \nal (64min)3, Dewan et al (54.5 min)12, Bharatnur \net al (65 min)13 and Bhadra (55 min)14 and by \nSeth in his personal series of 5655 cases1,2. \nUsually operating time depends on surgeon’s \nskill, size of uterus, and some associated factors \nlike presence of fibroid and adhesions. Mean \nblood loss was 60ml. It was lesser than that of \nother studies (268-316 ml).3,12-14 Operation time \nand blood loss were directly proportional to the \nsize of uterus & presence of fibroid. Most of the \npatients were discharged at 3rd postoperative \nday. The posoperative hospital stay was shorter \nthan the average stay of 7-8 days for abdominal \nhysterectomy in our hospital. Hospital stay 0f 2-\n5 days is reported in other studies.18-19 We did \nnot encounter any bladder, ureteric or rectum \ninjury. In one study of 3076 vaginal \nhysterectomies, it was found that the incidence \nof urinary intestinal tract injuries was 1.7 and \n0.5% respectively.23 Major complications were \nless due to thorough preoperative selection of \ncases. There were minor complications like \nfebrile morbidity in 8% cases and urinary tract \ninfection in 7% cases. In our study 72% patients \nhad no complains at their 12 weeks \npostoperative follow up, 17% were lost from \nfollow up, 3% complains of dyspareunia, 5% \nexperienced lower abdominal pain and 3% \ndeveloped vaginal discharge due to vault \ngranuloma.  \n \nThere are lots of advantages of NDVH over the \nabdominal hysterectomy, which are absence of \nscar, no adhesions, no risk of incisional hernia, \nno wound gap, associated uro-gynecological \nprocedures can also be performed. Operative \ntime, blood loss, anaesthetic complications, \nchance of injury to bowel, bladder and ureter, \nbowel handling leading to paralytic ileus are \nlesser than abdominal approach. Shorter hospital \nstay, fast recovery, low cost, less \nthromboembolic phenomena, less mortality and \nmorbidity are other benefits of vaginal \napproach.24,25 \n \nConclusion: \nDetail preoperative assessment and examination \nunder anaesthesia is an important part to choose \nthe route of hysterectomy. Mobility, size of \nuterus, vaginal capacity and laxity along with \ngood surgical skill and expertise in debulking \ntechniques are an integral part. A combination of \nmorcellation techniques is required and surgeon \nneeds to be familiar with these. Our study \nconcludes that non descent vaginal hysterectomy \nis more feasible, safe in moderately enlarged \nuterus even up to 20 weeks. NDVH is safe in the \nhands of an expert vaginal surgeon however \ndecision of route should be individualized \ndepending upon the best option for the patient. \nThis scarless approach need to be preferred \nrather than restricted for traditional utero-vaginal \nprolapsed surgery. \n \nReferences \n1) Sheth SS. Vaginal hysterectomy in: PurIR, \nMalhotra N. eds.Operative Obstetrics \nGynaecology. New Delhi. Jaypeebrother’s \nmedical publishers. 2009:499-510. \n2) Sheth SS. Paghdiwalla K P in:Saralya UB, \nRao A K, Chateerjee A. eds. Principles and \nPractice of Obstetrics and Gynaecology, \n2nded.New Delhi. Jaypee brother medical \npublishers. 2003:374-30 \n3) Goel N, Rajaram S, GhummanS.eds. step by \nstep Non-Descent vaginal hysterectomy. New \nDelhi. Jaypee brothers medical publishers \n2003; 423-5. \n4) Landeen LB. Bell MC. Hubert HB. Bennis \nLY. Knutsen-Larson SS. Seshadri-Kreaden \nU. Clinical and cost comparisons for \nhysterectomy via abdominal. Standard \nlaparoscopic. Vaginal and robot-assisted \napproaches. S DMed. 2011 Jun. 64(6):197-9. \n5) Meikle SF, Nugent EW, Orleans M. \nComplications and recovery from \nlaparoscopic-assisted vaginal hysterectomy \ncompared with abdominal and vaginal \nhysterectomy. ObstetGynecol 1997:89:304-\n11. \n\nJournal of Sylhet Women’s Medical College (JSWMC)  ISSN: 2708-2857 (P), 2710-0405 (O) \nJournal.swmc.edu.bd 2022 July; Volume 12; Issue 02 \n79 \n \n6) Ransom SB, Mc Neeley SG, White C, \nDiamond MP. A cost analysis of endometrial \nablation, abdominal hysterectomy, vaginal \nhysterectomy and laparoscopy – assisted \nvaginal hysterectomy in the treatment of \nprimary menorrhagia. J Am Assoc \nGynaecolLaparosc. 1996; 4(1):29-32.  \n7) Unger JB. Vaginal hysterectomy for the \nwomen with moderately enlarged uterus \nweighing 200 to 700grams. Am J \nObstelGynaecol 1999:180:1337-44. \n8) Farhana Dewan, Laila Arjuman Banu, \nAnowara Begum. Vaginal hysterectomy for \nNondescent Uterus. Bangladesh Journal of \nobstetrics and gynaecology 2003:1:21-25. \n9) Thomas G. Stovall. Hysterectomy. Berek& \nNovak’s Gynecology 14thedition . 2007; 22 \n©; 805. 6. \n10) Saha R, Shrestha NS,  Thapa M, et al. Non-\ndescent Vaginal Hysterectomy: Safety and \nFeasibility. NJOG 2012; 7 (2); 14-16. \n11)  Johnson N, Barlow D, Lethaby A, Tavender \nE, CurrL,Garry R. Methods of hysterectomy: \nSystematic review and meta-analysis of \nrandomized controlled trial. BMJ \n2005;330:1478. \n12) Dewan R, Agarwal S, Minocha B, Sen SK. \nNon-Descent vaginal hysterectomy-An \nexperience. J ObstetGynecol \nInd.2004;54(4):376-8. \n13) Bharatnur S Comparative study of abdominal \nversus vaginal hysterectomy in Non-Descent \ncases. Internet J Gynecol Obstet. \n2010;15(2):1528. \n14)  Bhadra B, Choudary AP, Tolassaria A, \nNupur N. Non-Descent Vaginal hysterectomy \n(NDVH): Personal experiences in 158 cases. \nAL Ameen J Med Sci.2011;4(1):23-7. \n15) Dicker RC, Greenspan JR, Strauss LT etal, \nComplications of vaginal and abdominal \nhysterectomy among women of reproductive \nage in the United States. Am J Obstet \nGynecol. 1982;144:841-8. \n16) Shital T  Mehta , Yamini N Trivedi , Pratik \nBhalodia. Role of non-descent vaginal \nhysterectomy in advancing gynaecological \npractice. NHL Journal of Medical \nSciences/Jan 2014/Vol 3/Issue 1,55-58. \n17)  KW Cheung, TC Pun. 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Nondescent vaginal \nhysterectomy: A Rational surgical Approach; \nBandladesh L ObstetGynaecol, 2015; Vol. \n30(1): 15-19.  \n23) Mathevet P, Valencia P, Cousin C et al. \nOperative injuries during vaginal \nhysterectomy. Eur J Obstet1990:30(h  \nGynecolReprod Biol 2001;97:71-5. \n24)  Schwarz R: Choice of surgical route in \nhysterectomy:  GynekolRundsc \n1990:30(4):248-52. \n25)  Del Frat G, Soligo M et al : Vaginal and \nabdominal hysterectomy comparison and \nperspectives: Minerva Gynaecology 1996 \nMay: 48(5) 181-91.","source_license":"CC0","license_restricted":false}