Overview
Vaginal hysterectomy is a well-established minimally invasive operation in which the uterus is removed through the vagina, without an abdominal incision. It is commonly used for benign gynecologic conditions such as uterine fibroids, abnormal uterine bleeding, prolapse, and chronic pelvic symptoms when surgery is appropriate. A newer approach, vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy, or VANH, combines the vaginal route with endoscopic assistance to improve visualization and surgical precision.
This randomized controlled trial compared vaginal hysterectomy (VH) with VANH as a day-care procedure, meaning the goal was same-day discharge after surgery. Day-care or outpatient surgery is important because it may reduce hospital stay, improve comfort, and lower health care costs, provided safety is not compromised.
Why this study matters
For many patients and surgeons, the main question is not whether hysterectomy can be done minimally invasively, but which minimally invasive technique best balances safety, recovery, and efficiency. VH has long been considered a standard option for suitable patients. VANH is a more recent technique that may offer better visualization of the operative field, potentially less blood loss, and easier completion of additional procedures such as salpingectomy, the removal of the fallopian tubes.
Removing the fallopian tubes during hysterectomy is increasingly recommended when appropriate because it may reduce the future risk of high-grade serous ovarian cancer, while generally preserving the ovaries in patients who do not need oophorectomy. This is often called opportunistic salpingectomy.
Study design
The trial was a single-blind, multicenter randomized controlled study conducted in two Dutch non-academic teaching hospitals. Women aged 18 years or older who were scheduled for hysterectomy for benign indications were included. Participants were randomized in a 1:2 ratio to VH or VANH.
The main outcome was same-day discharge. Secondary outcomes included:
– operative time
– elective salpingectomy rate
– intraoperative blood loss
– complications classified by Clavien-Dindo grading
– pain scores using the numeric rating scale (NRS)
– analgesic use
– postoperative recovery using the Recovery Index-10 (RI-10)
– quality of life using EQ-5D-5L
The analyses were performed on an intention-to-treat basis, which means patients were analyzed in the groups to which they were originally assigned, regardless of any changes during treatment. This approach helps preserve the validity of the randomization.
Main findings
A total of 113 patients were included in the final analysis: 42 in the VH group and 71 in the VANH group.
Same-day discharge occurred significantly more often after VANH than after VH:
– VANH: 87.3%
– VH: 71.4%
This difference was statistically significant, suggesting that VANH may be better suited to outpatient care.
VANH also showed several intraoperative advantages:
– shorter operative time: median 55 minutes versus 65 minutes for VH
– lower blood loss: median 50 mL versus 150 mL for VH
– more frequent elective salpingectomy: 100% versus 77.4% for VH
Pain scores in the first hour after surgery were lower in the VANH group. This early difference suggests that patients may feel more comfortable immediately after the operation, although this did not translate into measurable long-term differences in recovery or quality of life.
Importantly, postoperative complications were not statistically different between the two groups:
– VH: 9.5%
– VANH: 15.5%
Readmission rates were also not significantly different:
– VH: 4.8%
– VANH: 8.5%
Analgesic use, overall recovery scores, and quality-of-life measures were similar between groups.
Understanding the results
The trial suggests that VANH may offer practical benefits over conventional VH in a day-care setting. The higher same-day discharge rate is clinically meaningful because it reflects a smoother immediate postoperative course and better alignment with outpatient surgery goals. Shorter operating time and lower blood loss also indicate that the procedure may be efficient and gentle in experienced hands.
The higher rate of salpingectomy is another important advantage. Because VANH provides endoscopic assistance, surgeons may have better access and visibility to remove the fallopian tubes more consistently when clinically appropriate. This could be valuable for patients who are candidates for opportunistic salpingectomy.
At the same time, the study did not show a significant difference in complications, readmissions, or longer-term recovery. That is reassuring: the improved technical and immediate postoperative outcomes with VANH did not come at the cost of increased harm.
Clinical implications
For patients eligible for vaginal hysterectomy, VANH may be a useful alternative when the surgical team has the necessary training and equipment. It may be especially attractive in centers aiming to increase outpatient hysterectomy rates while maintaining safety. However, the results should be interpreted in the context of surgical expertise, patient anatomy, and local resources.
Not every patient is a candidate for a vaginal approach, and not every hospital has the setup or experience to perform VANH routinely. Factors such as uterine size, degree of pelvic organ prolapse, prior pelvic surgery, body habitus, and the need for additional procedures may influence the choice of technique. Shared decision-making remains important, with discussion of the expected benefits, limitations, and potential risks.
Strengths and limitations
A major strength of this study is its randomized controlled design, which is one of the best ways to compare surgical techniques. The multicenter setting also improves the generalizability of the findings to real-world practice.
There are, however, some limitations to consider. The trial was conducted in two Dutch teaching hospitals, so the results may not automatically apply to other health systems or surgical teams with different levels of experience. In addition, the study size, while respectable, may not have been large enough to detect small differences in less common complications. Finally, as with many surgical trials, blinding is challenging, and surgeon skill can influence outcomes.
Bottom line
In this randomized trial, VANH outperformed conventional VH on several immediate surgical and discharge-related outcomes, including same-day discharge, operating time, blood loss, and successful opportunistic salpingectomy. Both procedures remained safe, with no significant differences in complications, readmissions, recovery, or quality of life.
Overall, VANH appears to be a safe and effective alternative to standard vaginal hysterectomy for selected patients undergoing surgery for benign gynecologic conditions, particularly when outpatient discharge is a priority.
