Choosing The Route of Hysterectomy

/

Here’s the RoshReview Question of the Week!

​​A 49-year-old P3003 woman presents to the clinic with a complaint of heavy menses for several years and asks for definitive management. She has a history of type 4 fibroids, all < 3 cm, and hypercholesterolemia. Her obstetrical history is significant for two vaginal deliveries and one cesarean section. On physical examination, her BMI is 31 kg/m2. Her uterus is anteverted, and the fundus reaches 3 fingerbreadths below the umbilicus. What surgical intervention would be most cost- and clinically effective for this patient?

Check if you got the right answer at the links above!

Reading: Committee Opinion 701 - Choosing the Route of Hysterectomy for Benign Disease 

Why do we do a hysterectomy?  

  • Hysts are one of the most common surgeries in the United States (per the CDC, over 600,000 are performed annually) 

  • Many of them are elective - ie. patients are choosing surgical option over medical for example  

What exactly are the ways to do a hyst anyway and why does route matter?

Note: We won’t go into exact techniques here since we are a podcast. However, some great resources include the Atlas of Pelvic Surgery online: http://www.atlasofpelvicsurgery.com/home.html

Also the textbook by Baggish and Karam: Atlas of Pelvic Anatomy and Gynecologic Surgery 

Vaginal hysterectomy 

  • First type of minimally invasive hysterectomy 

  • Advantages 

    • Preferred type of hysterectomy when possible due to no incisions on the abdomen and minimally invasive route 

    • High safety and low cost

      • Meta-analysis of seven trials report similar rates of visceral injury and long-term complication among vaginal and laparoscopic procedures 

    • Minimally invasive approach associated with faster recovery compared to laparotomy 

  • Disadvantages

    • Unfortunately, despite advantages, there are fewer vaginal hysts performed compared to others due to limited training, fewer numbers of hysts overall being performed and greater diversity of operative approaches 

    • Must remove cervix with this type of procedure - no option for supracervical hyst 

    • Small chance of converting to laparotomy 

Laparoscopic hysterectomy 

  • Usually performed with laparoscopic instruments via 3-4 small ports in the abdomen. Uterus can be morcellated and removed through a bag (morcellate in bag) or via the vagina 

  • Increasing in popularity 

  • Advantages 

    • Better visualization with minimally invasive surgery 

    • Can perform supracervical hyst if needed 

    • Can also perform last part vaginally for ease if needed 

    • May be easier in some obese patients 

  • Disadvantages 

    • Requires surgeon skilled in use of laparoscopy 

    • Certain patient populations with certain medical illnesses may not tolerate Trendelenburg position or pneumoperitoneum 

    • Possibility of conversion to laparotomy 

    • Slightly higher rate of vaginal cuff dehiscence compared to other routes of hyst (still low, like 0.64-1.1%) 

Robotic hysterectomy 

  • Very similar overall in terms of advantages and disadvantages to laparoscopic hysterectomy due requiring Trendelenburg and pneumoperitoneum, as well as minimally invasive course 

  • Advantages 

    • Superior visualization compared to traditional laparoscopy due to ability to move camera and 3D vision 

    • Mechanical improvement - wrists with robots 

    • Better stabilization of instruments 

    • Improved ergonomics for surgeons - you can sit down (as someone who has definitely passed out during a long case) 

    • Even more options for minimally invasive routes (ie. single port hyst) 

  • Disadvantages 

    • Additional surgical training 

    • Does not necessarily decrease time (in fact can increase cost and operating room times) 

      • Cost of instruments overall + cost of robot 

    • Lack of haptics (no tactile feedback) 

Abdominal hysterectomy  

  • Only non minimally-invasive technique 

  • Advantages

    • Visualization 

    • Ability to remove large masses and large uteruses 

    • Tactile feedback  

    • Lowest risk of vaginal cuff dehiscence compared to other methods 

    • Studies like the VALUE study and the eVALuate trial showed decreased rates of complications of abdominal hyst compared to laparoscopic hyst, but these studies are also old (1990s) 

  • Disadvantages 

    • Increased postoperative pain and length of stay (average LOS is 3 days after abdominal hyst) 

    • Increased risk of bleeding and infection 

    • Increased risk of VTE (also may be due to increased stasis) 

    • Increased risk of colonic stasis 

How do we pick the route of hysterectomy? 

Consideration of minimally invasive routes 

  • MIS should be considered whenever possible because of well-documented advantages over abdominal hysterectomy 

  • Vaginal hyst is preferred over other types due to cost, effectiveness, and overall outcomes 

  • Even if opportunistic salpingectomy is desired, these can be performed with vaginal hysterectomy 

Anatomy 

  • Size and shape of vagina and uterus + descent of uterus 

  • More difficult to perform a vaginal hysterectomy if there is no descent, if there is large uterus (bulky fibroids) and small introitus 

    • However, nulliparity is not a contraindication to vaginal hysterectomy 

    • Study showed that 92% of vaginal hysterectomies planned for women with no prior vaginal deliveries could be successfully completed 

  • Accessibility of the uterus also important - is there likely to be a lot of pelvic adhesive disease? (endometriosis) 

    • Large uterine size - morcellation has come under scrutiny previously 

    • However, still can morcellate in a bag 

    • Even if large, bulky uterus, can refer to skilled MIS surgeon

  • Need of concurrent procedures (ie. will the patient need their appendix removed as well?) 

  • Work up: 

    • Physical exam with evaluation of mobility of uterus on bimanual 

    • Evaluation for adnexal masses on bimanual 

    • Feel for fundal height 

    • Pelvic ultrasound may be helpful 

Surgeon comfort/preference 

  • Surgeon preference for other operative routes - no longer considered an appropriate reason to avoid vaginal approach 

  • Surgeon experience 

    • Average case volume

    • Available hospital technology, devices, and support 

Patient preference 

  • If patient desires supracervical hysterectomy, will need laparoscopic or abdominal approach 

  • However, no clinically significant difference in complication and uncertain benefit in terms of patient outcomes (ie. sexual function, urinary function, bowel function)

ACOG CO 701

Vulvovaginal Itching

/

Today we’re working up the classic GYN sick visit in vulvovaginal itching. We recommend The V Book by Elizabeth Stewart, MD, and though we haven’t read Dr. Jen Gunter’s The Vagina Bible yet, we’ve heard great things!

We start off the episode with a review of things that can cause itching, stratifying from benign to more worrisome. For benign causes, the primary culprit is vaginitis. Think yeast (Candida), bacterial vaginosis, or less commonly gonorrhea/chlamydia or trichomoniasis. Another benign cause is desquamative inflammatory vaginitis, that can be associated with large amounts of discharge. Genitourinary syndrome of menopause, or atrophic vagnitis, is another common cause in postmenopausal women.

Benign dermatoses of the vulva can include lichen planus, which manifests as a red or purplish raised rash, that can present as hypertrophic or ulcerative. It can further lead to lichen simplex chronicus, which is an area of thickened skin due to repeated excoriation. Lichen planus can also involve other areas of the body. Finally, benign dermatoses like eczema, contact dermatitis, or psoriasis can also affect the vulva.

More worrisome dermatoses can include lichen sclerosus. Generally benign, this is a chronic, progressive inflammatory mucocutaneous disease that peaks in prepubertal and in menopausal women. The skin becomes thin and parchment-paper or “cigarette paper”-like in consistency, whitening, and destruction of the architecture and narrowing of the vaginal introits. It can be worrisome, particularly in older women, because it can harbor vulvar intraepithelial neoplasia (VIN) or squamous vulvar cancer. Of course, both of those can also occur on their own, often in the context of HPV infection.

Another malignant dermatosis is extramammary Paget’s disease. In this case, the vulva have an eczematous appearance with slightly raised edges and a red background. This is rare, with the malignancy originating in the vulvar apocrine-gland-bearing skin cells.

Ok, so lots of things can cause this itching, but what should we do? Always start with a complete history and physical. Histories should have special focus on vulvar hygiene, as this is often the culprit. A physical exam should include all skin including the vulva, to rule out more significant dermatoses. With the vulva, we advise a “top down” systematic approach before proceeding with the speculum exam.

The gynecologists handy tool will be the wet mount. Vaginal pH should be < 4.5, and basic pHs may suggest infection or poor lactobacillus presence. Dropping 20% KOH solution on the slide will allow for better visualization of yeast, as well as allow for the performance of the whiff test. On microscopy, you should see plenty of squamous cells (large, squarish cells with small nucleus or no nucleus), compared to paranasal cells (small round cells with prominent nuclei). Sheets of squamous cells with paranasal cells suggests desquamative inflammatory vaginitis. Clue cells have stippled or fuzzy borders along squamous cells. Yeast often has the classic ‘budding pseudohyphae’ or ‘spaghetti and meatballs’ appearance.

Genital cultures may be helpful in identifying resistant or unusual organisms, such as Candida glabratta. If allergies are suspected, referral for patch testing may be worthwhile if avoidance isn’t feasible. Biopsy should be performed to rule out malignancy at ulcerating areas, with lichen sclerosus, or with other areas of concern.

With vulvar hygiene, go as simple as possible. As our mentor Dr. Crichton always says: if you wouldn’t put it in your eye, don’t put it on the vulva. Recommend cotton underwear during the day, no underwear at night; unscented detergents and soaps; only water on vulva; latex condoms and provide own lube with silicone lube; avoid panty liners every day, only during periods . Coconut oil makes for excellent personal moisturizer and lubricant.

If something is present, you should treat the condition. Infections should be treated with appropriate antimicrobials. Lichen planus should be given symptomatic treatment to stop itching. Lichen sclerosus often will need high potency steroids (i.e., clobetasol) to resolve. Malignancies will require excision with referral to oncology for true invasive cancers.