Comparison of 2 Methods of Vaginal Cuff Closure at Laparoscopic Hysterectomy and Their Effect on Female Sexual Function and Vaginal Length: A Randomized Clinical Study

doi:10.1016/j.jmig.2016.07.007

Journal of Minimally Invasive Gynecology

Volume 23, Issue 6, September–October 2016, Pages 986-993

https://doi.org/10.1016/j.jmig.2016.07.007 Get rights and content

Abstract

Study Objective

To compare the effects of the laparoscopic approach versus the vaginal route for the management of vaginal cuff closure during total laparoscopic hysterectomy on female sexual function in premenopausal patients with benign gynecologic conditions.

Design

A prospective study with a randomized, double-blind design (Canadian Task Force Classification I).

Setting

A university hospital.

Patients

Patients who were scheduled to have total laparoscopic hysterectomy because of benign conditions.

Interventions

Patients were randomized to vaginal cuff closure via the vaginal route versus the laparoscopic approach. The study included a total of 70 patients; 34 underwent the laparoscopic approach in the management of vaginal cuff closure, and 36 underwent the vaginal route.

Measurements and Main Results

Female sexual function and vaginal length were measured. The duration of total surgery was significantly shorter in the laparoscopic approach group compared with the vaginal route group (112.2 ± 36.5 vs 122.7 ± 53.6, p < .05). The total Female Sexual Function Index scores preoperatively and 3 months postoperatively were similar between the laparoscopic approach and vaginal route groups (all p > .05). Vaginal lengths 3 months postoperatively were significantly longer in the laparoscopic approach group compared with the vaginal route group (8.39 ± 0.90 vs 7.34 ± 1.17, p < .05). The duration of cuff closure was significantly shorter in the vaginal route group compared with the laparoscopic approach group (8.92 ± 2.23 vs 7.51 ± 2.5, p < .05). Preoperative vaginal lengths were significantly longer in comparison with 3 months postoperatively both in the laparoscopic approach and the vaginal route groups (all p < .05). The preoperative total Female Sexual Function Index scores were significantly higher in comparison with 3 months postoperatively both in the laparoscopic approach and the vaginal route groups (all p < .05).

Conclusion

The results of this study indicate that the laparoscopic approach for vaginal cuff closure might be preferable because of better postoperative vaginal length and a shorter duration of total surgery time.

Section snippets

Study Design

This was a prospective study with a randomized, double-blind design in a university hospital.

Population and Recruitment

All patients referred to the gynecologic surgery division of the Department of Obstetrics and Gynecology at Istanbul University School of Medicine, Istanbul, Turkey, between November 2014 and 2015 who were scheduled to undergo total laparoscopic hysterectomy because of benign conditions were invited to participate in the study during their first visit to the department.

Inclusion criteria were as

Results

One hundred sixty-five patients were scheduled for laparoscopic hysterectomy for benign gynecologic conditions between November 2014 and 2015. Ninety-five patients gave consent and met the inclusion criteria. Eight patients were excluded from the study postoperatively because their surgery was converted from laparoscopy to laparotomy, either because of intraoperative complications (hemorrhage in 2 patients) or intraoperative conditions (enlarged uterus in 2 patients, inability to tolerate

Discussion

In this study, we tried to evaluate postoperative sexual function and vaginal length between the vaginal route versus the laparoscopic approach in the management of vaginal cuff closure during total laparoscopic hysterectomy in a reproducible and valid manner. Reproducibility and validity were addressed by choosing homogeneous cohort groups of premenopausal patients with benign gynecologic conditions. Vaginal length was measured in a conventional manner, and sexual function was evaluated using

Conclusions

The approach for vaginal cuff closure after hysterectomy usually depends on the preference and the experience of the surgeon. The results of this study indicate that the laparoscopic approach for vaginal cuff closure might be preferable because of better postoperative vaginal length and a shorter total surgery time.

Acknowledgments

We would like to thank David F. Chapman, BSc, for editing the article.

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Cited by (15)

Psychosocial predictors of change in sexual activity and sexual function after hysterectomy in women with pelvic pain
2023, American Journal of Obstetrics and Gynecology
Potential impact on sexual function is an often-cited concern for many patients considering hysterectomy. The existing literature indicates that sexual function remains stable to slightly improved for most patients who undergo hysterectomy, but most studies demonstrate a small subset of patients in whom sexual function declines after surgery. Unfortunately, there is a lack of clarity as to surgical, clinical, and psychosocial factors that may influence the likelihood of sexual activity after surgery or the magnitude and direction of change in sexual function. Although psychosocial factors are strongly associated with overall female sexual function, there is minimal data exploring the potential impact of these factors on the change in sexual function after hysterectomy.
This study aimed to evaluate the relationship between baseline psychosocial factors and both sexual activity and sexual function at 6 months after hysterectomy.
Patients undergoing hysterectomy for benign, non-obstetric indications were prospectively recruited as part of an observational cohort study evaluating presurgical predictors of posthysterectomy outcomes on pain, quality of life, and sexual function. The Female Sexual Function Index was administered before hysterectomy and 6 months after surgery. Presurgical psychosocial assessments included validated self-reported measures of depression, resilience, relationship satisfaction, emotional support, and social participation.
Complete data was available for 193 patients, of whom 149 (77.2%) reported sexual activity at 6 months after hysterectomy. In the binary logistic regression model examining sexual activity at 6 months, older age was associated with a lower likelihood of sexual activity (odds ratio, 0.91; 95% confidence interval, 0.85–0.96; P=.002). Higher relationship satisfaction before surgery was associated with a greater likelihood of sexual activity at 6 months (odds ratio, 1.09; 95% confidence interval, 1.02–1.16; P=.008). As expected, preoperative sexual activity was associated with a greater likelihood of postoperative sexual activity (odds ratio, 9.78; 95% confidence interval, 3.95–24.19, P<.001). Analyses using Female Sexual Function Index scores were limited to patients who were sexually active at both time points (n=132 [68.4%]). The total Female Sexual Function Index score did not change significantly from baseline to 6 months, but there were statistically significant changes in several individual domains of sexual function. Patients reported significant improvement in desire (P=.012), arousal (P=.023), and pain (P<.001) domains. However, significant decreases were reported in orgasm (P<.001) and satisfaction (P<.001) domains. The proportion of patients who met the criteria for sexual dysfunction was quite high (>60%) at both time points, but there was not a statistically significant change in the proportion from baseline to 6 months. In the multivariate linear regression model, there was no relationship between change in sexual function score and any of the variables examined, including age, endometriosis history, pelvic pain severity, or psychosocial measures.
In this cohort of patients with pelvic pain undergoing hysterectomy for benign indications, both sexual activity and sexual function remained fairly stable after hysterectomy. Higher relationship satisfaction, younger age, and preoperative sexual activity were associated with a greater probability of sexual activity at 6 months after surgery. Psychosocial factors, such as depression, relationship satisfaction, and emotional support, and history of endometriosis were not related to change in sexual function among patients who were sexually active both before hysterectomy and at 6 months after surgery.
Incidence and Prevention of Vaginal Cuff Dehiscence after Laparoscopic and Robotic Hysterectomy: A Systematic Review and Meta-analysis
2021, Journal of Minimally Invasive Gynecology
Citation Excerpt :
Bowel evisceration occurred in 15 out of the 51 VCD cases (29%) in studies that reported it [15,16,18,26,29]. In 5 studies that reported the time of VCD presentation, the mean presentation time was 68.5 days (range 5–512 days) [15,16,24,26,29]. None of the included studies reported the rate of recurrence of VCD.
Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy.
PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered.
The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence.
A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11–0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13–1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00–3.88).
There is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation.
Sexual Function following Laparoscopic versus Transvaginal Closure of the Vaginal Vault after Laparoscopic Hysterectomy: Secondary Analysis of a Randomized Trial by the Italian Society of Gynecological Endoscopy Using a Validated Questionnaire
2020, Journal of Minimally Invasive Gynecology
The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire.
Secondary analysis of a prospective randomized controlled trial.
Three academic research centers.
Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included.
Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications.
A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (<26.55) had a significantly higher likelihood of having a postoperative sexual disorder (p <.001). Women who received bilateral adnexectomy before menopause and those with postoperative vaginal cuff hematoma had a significantly lower postoperative FSFI score (p = .001 and p = .04, respectively). After multivariable analysis, both variables maintained at least a tendency toward an association with a lower postoperative FSFI score (odds ratio, 2.696; 95% confidence interval, 1.010–7.194; p = 0.048 and p = 0.053; odds ratio, 13.2; 95% confidence interval, .966–180.5, respectively).
Transvaginal and laparoscopic cuff closures after TLH have similar sexual postoperative outcomes. A patient with sexual problems before TLH is more likely to have a low FSFI score postoperatively. Premenopausal patients undergoing bilateral ovariectomy and those with postoperative vaginal cuff hematoma have a worse postoperative sexual life.
(Clinicaltrials.gov, protocol number NCT02453165, registration date May 25, 2015.)
The Influence of Laparoscopic Benign Hysterectomy in Sexual Function
2023, Clinical and Experimental Obstetrics and Gynecology
Comparison of The Laparoscopic Approach Versus The Vaginal Route Closure of Vaginal Cuff during Total Laparoscopic Hysterectomy
2023, The Egyptian Journal of Hospital Medicine
A multimodal concept for vaginal cuff closure by modification of the Bakay technique in total laparoscopic hysterectomy: a randomized clinical study
2022, BMC Women's Health

View all citing articles on Scopus

: The authors declare that they have no conflict of interest.

: Supported by the Scientific Research Projects Coordination Unit of Istanbul University (grant no. 48890).

View full text

Original ArticleComparison of 2 Methods of Vaginal Cuff Closure at Laparoscopic Hysterectomy and Their Effect on Female Sexual Function and Vaginal Length: A Randomized Clinical Study

Abstract

Study Objective

Design

Setting

Patients

Interventions

Measurements and Main Results

Conclusion

Section snippets

Study Design

Population and Recruitment

Results

Discussion

Conclusions

Acknowledgments

Respective consequences of abdominal, vaginal, and laparoscopic hysterectomies on women's sexuality

Eur J Obstet Gynecol Reprod Biol

Sexuality after total vs. subtotal hysterectomy

Acta Obstet Gynecol Scand

Hysterectomy and women satisfaction: total versus subtotal technique

Arch Gynecol Obstet

The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function

J Sex Marital Ther

Research on the menopause in the 1990s. Report of a WHO Scientific Group

World Health Organ Tech Rep Ser

The Clavien-Dindo classification of surgical complications: five-year experience

Ann Surg

Vaginal length and incidence of dyspareunia after total abdominal versus vaginal hysterectomy

Eur J Obstet Gynecol Reprod Biol

Validation of the Female Sexual Function Index (FSFI) in women with female orgasmic disorder and in women with hypoactive sexual desire disorder

J Sex Marital Ther

The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores

J Sex Marital Ther

Reliability and validity of the female sexual function index in Turkish population

Sendrom

Vaginal cuff closure with absorbable bidirectional barbed suture during total laparoscopic hysterectomy

Eur J Obstet Gynecol Reprod Biol

Group C. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials

Open Med

Comparison of vaginal and abdominal hysterectomy: a prospective non-randomized trial

Pak J Med Sci

Vaginal versus robotic hysterectomy and concomitant pelvic support surgery: a comparison of postoperative vaginal length and sexual function

J Minim Invasive Gynecol

Determinants of vaginal length

Am J Obstet Gynecol

Original Article
Comparison of 2 Methods of Vaginal Cuff Closure at Laparoscopic Hysterectomy and Their Effect on Female Sexual Function and Vaginal Length: A Randomized Clinical Study