Non-Descent Vaginal Hysterectomy in Benign Uteri: Feasibility, Perioperative Outcomes, and a Preoperative Feasibility Score

Aims and Objectives. Non-descent vaginal hysterectomy (NDVH) remains an underutilised route despite being scarless, regional-anaesthesia-compatible, and resource-sparing. In an era dominated by laparoscopic and robotic surgery, its feasibility in contemporary practice deserves re-evaluation. We aimed to (i) assess the feasibility and perioperative outcomes of NDVH in women with benign, non-prolapsed uteri up to 14 weeks in size, and (ii) evaluate whether a composite preoperative feasibility score, built from five routinely available clinical parameters, stratifies anticipated surgical difficulty and observed morbidity.Methods. Retrospective observational case series at a tertiary teaching referral centre (October 2022–October 2024). Consecutive eligible women had a benign indication, a non-prolapsed uterus ≤14 weeks, and no adnexal pathology. A composite score (age, vaginal parity, previous pelvic surgery, comorbidity, uterine size; each 0–2; total 0–10) classified cases as easy (0–3), moderately difficult (4–6), or difficult (7–10). Outcomes were operative time, estimated blood loss (EBL), transfusion, hospital stay, and intra-/post-operative complications. Associations between the score and outcomes were tested with Spearman correlation and, across the three score categories, with the Kruskal–Wallis and χ² tests; individual score components (prior caesarean/pelvic surgery, uterine size) were examined secondarily with Mann–Whitney U and Fisher's exact tests.Results. Thirty women underwent NDVH (mean age 46.4 ± 5.3 years; 96.7% multiparous; 60.0% with prior pelvic surgery, predominantly caesarean). By FIGO PALM-COEIN grouping, leiomyoma-related disease (AUB-L) was the leading indication (20 women, 66.7%), followed by adenomyosis-related disease (AUB-A; 8, 26.7%) and abnormal uterine bleeding not otherwise specified (AUB-NOS; 2, 6.7%). The uterus was removed vaginally in all 30; 1 (3.3%) required laparotomy for haemostasis. Debulking was used in 12 (40%). Mean operative time was 168.5 ± 29.7 min and mean EBL 216.7 ± 64.8 mL; transfusion was required in 5 (16.7%). Any complication occurred in 10 patients (33.3%): post-operative fever- 5 (16.7%), urinary tract infection- 2 (6.7%), transient urinary retention- 2 (6.7%), bladder injury- 1 (3.3%), ureteric injury- 1 (3.3%), and laparotomy for haemostasis- 1 (3.3%); no bowel injury occurred. Outcomes deteriorated monotonically across score categories: complications 16.7% → 28.6% → 100%, EBL 183 → 232 → 262 mL, operative time 161 → 165 → 202 min, and transfusion 0% → 14.3% → 75% for easy, moderate, and difficult groups. The score correlated with EBL (ρ=0.5, p=0.007), operative time (ρ=0.5, p=0.004), hospital stay (ρ=0.5, p=0.002), and complications (ρ=0.5, p=0.005).Conclusion. In appropriately selected women with benign, non-prolapsed uteri ≤14 weeks, NDVH is feasible, but morbidity in this tertiary cohort was substantial and rose steeply with the preoperative feasibility score. The score is therefore best positioned as a graded decision aid: it identifies the low-morbidity majority who are ideal vaginal candidates, and flags the high-difficulty minority in whom either a modified vaginal strategy or an alternative route, senior operator, and prophylactic measures should be planned. External validation in a larger, prospective, multicentre cohort is required.