Vaginal Hysterectomy

What is a vaginal hysterectomy?

A vaginal hysterectomy is removal of the uterus and cervix through a vaginal incision.  There are no incisions on the abdomen. 

Should I keep or remove the ovaries and fallopian tubes?

For most women, we recommend that patients keep their ovaries as long as the ovaries appear normal.  The removal of the ovaries prior to menopause has been shown to increase the risks of heart disease and osteoporosis (weakening of the bones).  If the ovaries are left in place, there is a low risk of developing cysts (either benign or cancerous) the future that may require further surgery, and you will need to continue to have annual pelvic exams to assess for ovarian masses.

Once a hysterectomy is performed, the fallopian tubes are no longer necessary.  After hysterectomy, a remaining fallopian tube can form a cyst, called a hydrosalpinx, which can cause pain.  We think that some ovarian cancers may actually come from the fallopian tubes.  Since there is very little risk to removing the fallopian tubes, we recommend trying to removing both fallopian tubes (bilateral salpingectomy) at the time of hysterectomy, but sometimes this is not possible with a vaginal hysterectomy.

What can I expect? 

You will be admitted to the hospital the day of your procedure.  You will stay in the hospital overnight and will be discharged home in the morning.

You will need to return to clinic in 6 weeks to see your doctor for a postoperative visit.

Most patients can return to work and most of their usual activities in 4-6 weeks. A detailed review of your postoperative instructions will be reviewed at your preoperative appointment, and again prior to your discharge from the hospital.  Vaginal intercourse should be avoided for at least 8 weeks after surgery. 

What are the risks of the surgery?

Although there can be problems that result from surgery, we work very hard to make sure it is as safe as possible. However, problems can occur, even when things go as planned, and you should be aware of these risks.

Possible risks during surgery include:

1. Bleeding: If there is excessive bleeding, you will be given a blood transfusion unless you have personal or religious reasons for not wanting blood. This should be discussed with your doctor prior to the surgery.
2. Damage to other organs, such as the bowel, bladder, ureters (the tubes that drain the kidneys into the bladder), blood vessels and nerves. Damage occurs in less than 1% of surgeries. Some injuries may not be recognized at the time of surgery and may require re-hospitalization and/or a second surgery.
3. Conversion to an open surgery requiring an up-and-down or Bikini incision or a laparoscopic surgery: If a bigger open incision is needed during your surgery, you may need to stay in the hospital for one or two nights.
4. Death: All surgeries have a risk of death. Some surgeries have a higher risk than others.

Possible risks that can occur days to weeks after surgery include:

1. Urinary retention: Inability to feel the urge to urinate and/or empty your bladder. This is usually temporary and usually resolves in 12-72 hours after the surgery. Prior to discharge, the nursing team will check and make sure that you can adequately empty your bladder. If you are unable to adequately empty your bladder after surgery, you will need to use a catheter to drain your bladder until your symptoms resolve. If this occurs, our nurses will teach you how to do this safely before going home. 

2. A blood clot in the legs (deep venous thrombosis, DVT) or lungs (pulmonary embolus, PE): Swelling or pain in your legs, shortness of breath, or chest pain are possible signs of blood clots. This is considered an emergency. Call you doctor immediately if you experience swelling or pain in your legs. Call 911 or go to the nearest emergency room if you develop chest pain or shortness of breath. 

3. Bowel obstruction: A block in the bowel that results in not being able to pass stool or gas. May cause stomach pain, bloating or vomiting. This may require hospitalization or another surgery. 

4. Infection: This includes infection of the bladder, kidneys, skin or the site of surgery. This may cause fever, redness, swelling or pain. This may require treatment with antibiotics, admission to the hospital, and possible drainage of infected tissue or fluid. 

5. Hernia: Weakness in the muscle at the incision that allows a piece of intestine or the tissue around them to pass through. This can cause a lump under the skin and sometimes, an organ or tissue gets stuck in the hernia, which can cause problems.
6. If you choose to keep your cervix, you may continue to have cyclic bleeding. You will also need to continue to have pap smears 

7. If you choose to remove your cervix, there is a 1-3% risk that the vaginal stitches may open up, which is called a vaginal cuff dehiscence. This is a rare postoperative complication that may require an emergency surgery to close it again 

8. Persistent pain that does not get better after surgery. Or, onset of new pelvic or abdominal pain that was not present before surgery. 

9. Failure to relieve symptoms or recurrence of the symptoms for which you are having hysterectomy. 

10. Development or recurrence of scar tissue 

11. Occasionally, your surgeon may need to cut your uterus into smaller pieces during the hysterectomy (This is called “morcellation“). This is sometimes done to help see critical structures during the surgery, to minimize the size of the abdominal incision, or if you choose to keep your cervix. Morcellation is only an option for women if the risk of cancer in the uterus is thought to be low. Most uterine tissue (including fibroid tumors) are benign (non-cancerous). However, there is no medical test that can accurately detect all cancers before surgery and cancer within fibroid tumors or the uterine wall are extremely difficult to diagnose before surgery. We estimate the risk of an undetected cancer in a women undergoing hysterectomy is less than 1 in 500.  If the uterus contains an undetected cancer, morcellation of the uterus may spread cancer cells within the abdomen.  This may make the cancer more difficult to treat and may worsen the chances for survival, although the prognosis for this type of cancer is poor even when the uterus is removed in one piece. Sometimes, the only way to perform a hysterectomy without morcellation is to make a large incision on the abdomen.  Larger incisions on the abdomen can be associated with increased postoperative pain, longer recovery, more blood loss, higher risk of infection, and higher risk of wound healing problems.  Please discuss whether morcellation will be considered for your surgery.