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abstract

205 - REMOVING THE ADNEXA DURING VAGINAL HYSTERECTOMY - WHAT ARE THE CHANCES OF SUCCESS AND SHOULD IT CHANGE THE SURGICAL ROUTE?

205

REMOVING THE ADNEXA DURING VAGINAL HYSTERECTOMY - WHAT ARE THE CHANCES OF SUCCESS AND SHOULD IT CHANGE THE SURGICAL ROUTE?

NG1, K. NG 2;
1Natl. Univ. Hosp. of Singapore, Singapore, Singapore, 2Natl. Univ. Hosp., Singapore, Singapore, Singapore.

Introduction: With the spotlight being increasingly focused upon newer approaches of hysterectomy - namely, laparoscopic and robotic - the surgical techniques of removing the adnexa at the time of vaginal hysterectomy remains an important asset to the modern gynaecologist [1]. While it is a known fact that the adnexa may not always be surgically accessible during vaginal hysterectomy, the evidence surrounding pre-operative prediction of successful adnexectomy in prolapse cases remains scant - hence contributing to a counseling dilemma when the topic of prophylactic bilateral salpingo-oopherectomy is broached.
Objective: In this retrospective study, we sought to find an association between pre-operative pelvic organ descent - in particular, point C (cervix) and point D (posterior fornix/ Pouch of Douglas) of Pelvic Organ Prolapse Quantification System (POP-Q) and the chance of successful adnexectomy at the time of vaginal hysterectomy. As such, we aim to improve the pre-operative counseling of patients - in particular, those who express desire towards prophylactic bilateral salpingo-oopherectomy during vaginal hysterectomy.
Methods: 146 patients in total underwent vaginal hysterectomy for the indication of pelvic organ prolapse in a tertiary hospital institution by a single lead urogynaecologist from 1st January 2013 to 31st October 2016. Clinic and operative records were retrieved from the hospital electronic computer system. Stages of prolapse were assigned pre-operatively in accordance to the POP-Q system and keyed into standardized electronic urogynaecology examination templates. 21 patients (18 pre-menopausal and 3 peri-menopausal) were excluded due to desire for ovarian conservation following pre-operative discussion. 125 patients were included in the final analysis - all were peri-menopausal or menopausal - with the pre-operative intention for bilateral salpingo-oopherectomy at the time of vaginal hysterectomy.
Results: The average age of patients was 64 years old (ranging from 51 to 82 years old), with parity ranging from 0 to 8 (average 3). 47.2% (59 out of 125) of patients had successful bilateral salpingo-oopherectomy at the time of vaginal hysterectomy. Patients with successful adnexectomy had an average point C of +4.5 (ranging from +1.5 to 8) and an average point D of 0 (ranging from -2 to 0), whilst those who did not manage to have a successful bilateral salpingo-oopherectomy at the time of vaginal hysterectomy had the same average point C value but an average point D of -2.5 (ranging from -4 to -1). In patients who failed to have concurrent removal of their fallopian tubes and ovaries, 100% was attributed to surgical inaccessibility of the adnexa (which were either pre-operatively seen to be normal on ultrasound pelvis or intra-operatively visualized/palpated to be unremarkable).
Conclusions: While prophylactic salpingo-oopherectomy with its theoretical benefits may be offered to patients considering hysterectomy for benign gynecological reasons, the chosen route of hysterectomy should not be unduly influenced [1-3]. Clinicians should keep in mind that this should not constitute a contraindication to vaginal hysterectomies as the vaginal approach has been time-tested to be the least expensive, minimally invasive surgical option associated with the lowest major complication rates [4-5]. While limited by small numbers, our study has shown a success rate of 47.2% of concurrent adnexectomy at the time of vaginal hysterectomy with a positive association of point D - namely, the lower point D, the higher the chance of successful bilateral salpingo-oopherectomy at the time of vaginal hysterectomy. We await future larger scale prospective trials regarding this, and hope that this information proves helpful in the pre-operative counseling of such patients, which will be vital in the process of obtaining informed consent and the subsequent management of patients’ expectations.
References: 1) Shepherd JP, Zyczynski HM. Removal of adnexa at the time of vaginal hysterectomy. Clin Obstet Gynecol. 2010 Mar;53(1):17-25. doi: 10.1097/GRF.0b013e3181ce87fc.
2) ACOG Committee Opinion No. 444: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009 Nov;114(5):1156-8.
3) ACOG Committee Opinion No 620: Salpingectomy for Ovarian Cancer Prevention. Obstet Gynecol. 2015 Jan;125(1):279-81. doi: 10.1097/01.AOG.0000459871.88564.09.
4) Landeen LB, Bell MC, Hubert HB, Bennis LY, Knutsen-Larson SS, Seshadri-Kreaden U. Clinical and cost comparisons for hysterectomy via abdominal, standard laparoscopic, vaginal and robot-assisted approaches. S D Med. 2011 Jun;64(6):197-9. 201, 203. passim.
5) Gupta J. Vaginal hysterectomy is the best minimal access method for hysterectomy. Evid Based Med. 2015 Dec;20(6):210. doi: 10.1136/ebmed-2015-110300. Epub 2015 Oct 7.