Vaginal Hysterectomy
Vaginal hysterectomy (VH) removes the uterus and cervix through the vagina. For benign disease, ACOG recommends the vaginal route when feasible; laparoscopic hysterectomy is an alternative when vaginal access is unsuitable. Route selection also depends on the planned operation, anatomy, surgeon experience and the informed patient's preferences.[1]
For uterine prolapse, hysterectomy must be accompanied by an apical-support repair. Removing the uterus does not correct the support defect. Uterine preservation remains an option for appropriately selected patients who prefer it; hysterectomy is not an obligatory component of prolapse treatment.[2]
For treatment selection, see Prolapse Repair. Operative companions include McCall Culdoplasty, Uterosacral Ligament Suspension, Sacrospinous Ligament Fixation, and the uterus-preserving Sacrospinous Hysteropexy and Manchester-Fothergill Procedure pages.
Indications and route selection
Establish the indication for hysterectomy before choosing its route. Common benign settings include symptomatic prolapse when hysterectomy is selected, persistent abnormal uterine bleeding, symptomatic fibroids and adenomyosis after discussion of appropriate alternatives. A diagnosis of cervical dysplasia or endometrial hyperplasia alone is not an automatic indication for this operation; premalignant or malignant disease requires its own diagnostic and treatment pathway.[1][3]
| Assessment | Implication for planning |
|---|---|
| Uterine size, shape, mobility and descent | Assess exposure and safe extraction; size alone does not supply a universal cutoff |
| Vaginal access | Evaluate working space, not simply parity or a history of vaginal delivery |
| Prior cesarean or pelvic surgery | Neither is an absolute contraindication; distorted bladder planes and adhesions can change the operative plan |
| Extrauterine disease or adnexal pathology | Endometriosis, adhesions and required concurrent procedures may favor laparoscopic assistance or another route |
| Prolapse and patient goals | Agree on uterine preservation versus removal, the apical repair, and any additional compartment or continence procedure |
| Expertise and resources | Choose an approach the team can perform safely, with a plan for additional exposure or conversion if necessary |
These factors are considered together; feasibility in selected expert-center series does not establish that every patient is a vaginal candidate.[1][2][4]
Operative framework
The sequence changes with anatomy and the planned suspension. These are the core stages of conventional VH, with detailed apical reconstruction on the linked technique pages.[4][5][6]
- Exposure and preparation. Position in supported lithotomy, drain the bladder, perform vaginal antisepsis and establish adequate lighting and retraction. Confirm the planned adnexal and prolapse procedures.
- Cervicovaginal incision and dissection. Incise at the cervicovaginal junction and develop the vesicocervical plane with controlled dissection. Prior cesarean delivery may distort this plane.
- Peritoneal entry. Identify and enter the anterior and posterior reflections under controlled exposure. Anterior-first entry is not mandatory. When access is difficult, posterior-first entry or staged extraperitoneal pedicle control may help; do not force entry through an uncertain plane. Linder describes bladder illumination as an additional troubleshooting aid.[6]
- Pedicle control. Secure, divide and confirm hemostasis of the uterosacral/cardinal attachments, uterine vessels and upper pedicles as exposure permits. Keep the bladder, ureters and bowel clear of the clamp, needle and active energy jaws. The upper pedicle differs when the ovaries are preserved versus removed.
- Specimen delivery. Remove the uterus intact when feasible. If vaginal debulking or manual fragmentation is contemplated, establish an appropriate preoperative malignancy assessment, extraction plan and consent; it is not a mandatory percentage of cases or a generic substitute for oncologic planning.[1]
- Hemostasis, suspension and closure. Reassess all pedicles, complete the chosen apical repair and close the cuff without compromising the planned vaginal length or support. Cuff orientation alone does not establish better sexual function. The 2017 SGS review reported a length difference with vertical closure, but evidence for many individual steps was limited.[2][4]
- Urinary-tract assessment. For vaginal uterosacral suspension, perform intraoperative cystoscopy to assess the bladder and bilateral ureteral patency after suspension. Follow the specific repair's technique and injury-evaluation pathway.[2]
Routine postoperative vaginal packing is not supported by the 2017 SGS review. Selective packing for a defined clinical reason requires an explicit removal plan.[4]
Vessel sealing vs suture ligation
Clamp-cut-ligate and bipolar vessel sealing are alternative methods of pedicle control. A vessel sealer can shorten this part of the operation, but does not replace apical reconstruction or establish protection from ureteral, bladder or bowel injury.
The 2024 Society of Gynecologic Surgeons systematic review included 19 comparative pedicle-sealing studies. Its supplemental evidence table reports approximately 16 minutes shorter surgery (mean difference −15.9; 95% CI −23.3 to −8.5) and 37 mL less blood loss (−36.9; −56.9 to −17.0). Stay and pain differences were modest and heterogeneous; pooled opioid use did not show a clear reduction. These averages do not prove fewer major complications or the same benefit in every difficult case.[7]
Use the selected device within its instructions, under direct exposure, and avoid incorporating adjacent structures. Inadequate sealing and unintended thermal injury are distinct hazards; suture hemostasis must remain available. Neither a fixed number of saved ligatures nor a universal cost saving should be promised. The device evidence applies to vaginal operations, not automatically to abdominal hysterectomy or other reconstruction.[7][8]
Concurrent procedures
- Apical suspension: part of hysterectomy for uterine prolapse; choose the specific repair according to support defects and patient goals.[2]
- Other compartment and continence procedures: plan from symptoms, examination and shared decisions; they are not automatic additions to every hysterectomy.
- Opportunistic salpingectomy: discuss when appropriate; it should not by itself change the intended hysterectomy route.[1]
- Ovarian conservation or oophorectomy: decide separately according to indication, age, ovarian pathology, cancer risk and preferences. Technical ability to remove the ovaries is not itself an indication for bilateral oophorectomy.[1]
Comparative outcomes
| Evidence | Clinically useful interpretation |
|---|---|
| Cochrane 2023: 63 RCTs, 6,811 participants across all route comparisons | VH versus abdominal hysterectomy probably permits earlier return to normal activities (about 11 days, four trials/274 women) and fewer wound infections. Differences in operating time, transfusion and uncommon visceral injuries remain uncertain. Recovery averages from older trials are not fixed postoperative restrictions.[3] |
| Meyer 2026: NSQIP 2012–2022 observational analysis | Among 83,436 matched patients, 30-day complications were 8.2% after VH versus 6.4% after laparoscopic/robotic hysterectomy. This is an association after matching, not randomized proof of a superior route; case selection, surgeon factors and concurrent surgery matter.[9] |
| Cassani 2026: 63-RCT urinary-injury network review | The review supports a ureter-injury signal for laparoscopic versus abdominal hysterectomy, but rare events, wide intervals, overlapping older trials and inconsistencies between text and supplements limit route rankings. It does not establish a universally safest vaginal, robotic or vNOTES approach.[10] |
| LAVA 2025 randomized trial | Compared laparoscopic with abdominal hysterectomy, not VH. Only 75 of 3,250 planned participants were randomized and 62 underwent surgery; the planned noninferiority conclusion could not be made. Similar observed recovery is not proof of equivalence.[11] |
Conventional VH and vNOTES
The 2026 VANH randomized trial analyzed 113 patients at two Dutch centers. Same-day discharge occurred in 87.3% after vaginal-assisted NOTES versus 71.4% after conventional VH (OR 2.76; 95% CI 1.04–7.25). Reported complications and readmissions did not differ significantly, but the sample cannot establish equivalent rare-event safety. This is short-term evidence about conventional endoscopic assistance, not a demonstration of robotic benefit or long-term prolapse durability.[12] See vNOTES and robotic platforms for the distinctions between techniques.
Complications and perioperative care
Counsel about bleeding, infection, bladder/ureter/bowel injury, retention, VTE, vaginal healing and the outcomes of any concomitant prolapse repair. Rates depend on indication, route definitions, follow-up and patient risk; a historical cuff-dehiscence percentage is not a universal personal prediction.
In FINHYST, prior cesarean delivery and uterine weight at least 500 g were associated with bladder injury (OR 4.01 and 2.88 respectively). These were adjusted associations across a mixed-route cohort, not VH-specific absolute risks or contraindications. Urinary injury can be recognized after surgery; new flank pain, urinary leakage, fever or unexpected recovery warrants evaluation.[13]
| Element | Practical approach |
|---|---|
| Infection prevention | Use hysterectomy-appropriate prophylaxis, with agent, allergy, weight and redosing decisions in Perioperative Antibiotic Prophylaxis |
| Analgesia | Individualized multimodal treatment; acetaminophen/NSAIDs when suitable, selected regional techniques and rescue opioids. Routine new gabapentin is not a default. See Analgesia |
| VTE prevention | Early mobilization and mechanical/pharmacologic measures matched to thrombotic and bleeding risk; see VTE Prophylaxis |
| Discharge and recovery | Confirm pain/nausea control, mobility and a voiding or catheter plan. Individualize graded activity and vaginal-healing advice to the complete operation, especially concurrent prolapse repair |
Videos
References
1. Committee on Gynecologic Practice. Committee Opinion No. 701: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2017;129(6):e155-e159. doi:10.1097/AOG.0000000000002112.
2. Sartori MGF, Brito LGO, Schreiner L, et al. Surgical treatment of apical prolapse: Number 9 – 2026. Rev Bras Ginecol Obstet. 2026;48:e-FPS9. Febrasgo position statement. doi:10.61622/rbgo/2026FPS9. Full text.
3. Pickett CM, Seeratan DD, Mol BWJ, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2023;8:CD003677. doi:10.1002/14651858.CD003677.pub6.
4. Jeppson PC, Balgobin S, Rahn DD, et al. Comparison of vaginal hysterectomy techniques and interventions for benign indications: a systematic review. Obstet Gynecol. 2017;129(5):877-886. doi:10.1097/AOG.0000000000001995.
5. Stark M, Malvasi A, Mynbaev O, Tinelli A. The renaissance of the vaginal hysterectomy — a due act. Int J Environ Res Public Health. 2022;19:11381. doi:10.3390/ijerph191811381. Full text.
6. Linder BJ, Gebhart JB. Entry into the anterior cul-de-sac during vaginal hysterectomy. Int Urogynecol J. 2018;29(8):1223-1225. doi:10.1007/s00192-018-3646-y.
7. Balgobin S, Balk EM, Porter AE, et al; Society of Gynecologic Surgeons Systematic Review Group. Enabling technologies for gynecologic vaginal surgery: a systematic review. Obstet Gynecol. 2024;143:524–537. doi:10.1097/AOG.0000000000005522. Supplemental evidence tables and analyses.
8. Davidson ERW, Kho R. Use of vessel-sealing devices during vaginal hysterectomy. J Minim Invasive Gynecol. 2019;26(2):362. doi:10.1016/j.jmig.2018.04.018.
9. Meyer R, Hamilton KM, Ezike O, et al. Vaginal hysterectomy vs laparoscopic hysterectomy for benign indications: complications and length of stay in a national analysis of contemporary data. Am J Obstet Gynecol. 2026;234(3):620-631. doi:10.1016/j.ajog.2025.10.027.
10. Cassani C, Spinillo A, Dominoni M, Gardella B. Revisiting urological injury risks in minimally invasive hysterectomy for benign indications: a rare-events network meta-analysis with sensitivity analyses. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06566-y.
11. Antoun L, Woolley R, Middleton L, et al. Comparison of complications and recovery after laparoscopic and abdominal hysterectomy for benign disease: the LAparoscopic Versus Abdominal hysterectomy (LAVA) randomised controlled trial. BMJ Open. 2025;15:e096265. doi:10.1136/bmjopen-2024-096265. Full text.
12. Bekkers IPW, Wintraecken FRM, Smeets NAC, et al. Vaginal hysterectomy versus vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy; results of a randomised controlled trial. BJOG. 2026. doi:10.1111/1471-0528.70260.
13. Brummer TH, Jalkanen J, Fraser J, et al. FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors. Hum Reprod. 2011;26(7):1741-51. doi:10.1093/humrep/der116.