Distance of Cervico-Vaginal Junction to Anterior Cul-de-sac during Vaginal Hysterectomy in Patients with and without Prior Cesarean Section

Abstract

Study Objective Incomplete dissection of vaginal attachments to cervix during vaginal hysterectomy (VH) can lead to incorrect plane and injury to the bladder. This study aims to compare the mean distance between the cervico-vaginal (CV) incision to the anterior cul-de-sac (AC) during VH between women with and without a history of cesarean section (CS). Design Prospective cohort study of women who underwent VH. Intraoperative measurements taken: Distance from external cervical os to initial incision at CV, distance from CV to peritoneal entry into the AC, and distance from AC to the uterine fundus. Measurements were compared between patients with and without CS. We determined that 40 patients were needed to study our primary outcome: 20 CS and 20 non-CS. Setting VH performed in high lithotomy position. Patients or Participants Women who were undergoing VH for benign gynecologic conditions were included. Patients were excluded if gynecologic malignancy, prior vaginal or pelvic radiation, and/or presence of lower anterior uterine segment myoma. Interventions N/A Measurements and Main Results Preliminary data are presented (incomplete accrual as yet of patients due to the COVID19). Of the 35 patients with complete data, 23 (62.1%) had vaginal delivery(ies) only, 12 (32.4%) had at least one CS. The mean distance from CV to AC entry in all patients was 5.0 (1.55) cm, 5.4 (1.92) cm with CS, and 4.79 (1.31) cm without CS (p=0.27). The mean distance of the AC entry to fundus was longer in patients without CS (6.48cm vs 4.49cm, p=0.01). This finding remained significant when we controlled for both uterine length and weight. Conclusion Preliminary data suggests that in CS patients, the mean distance from the initial incision to AC tended to be greater and distance of AC to fundus was significantly shorter compared to non-CS patients.