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Sir,

We read with interest the commentary by Professor Garry on the best way to undertake a hysterectomy1: it is strange that this debate still persists despite evidence from randomised trials. Although Professor Donnez’s study2 is not randomised, his large series is impressive and there is no doubt that in the experienced hands of advanced endoscopic surgeon, the laparoscopic approach is both swift and relatively free of complications. However, in the current financial climate and with its long learning curve, laparoscopic hysterectomy is unlikely to become firmly established in most district general hospitals in the United Kingdom, especially when the latest Cochrane review on the subject published in 20063 concluded that vaginal hysterectomy (VH) should be performed in preference to total abdominal hysterectomy (TAH) and, if not possible, a laparoscopic approach may then be used. Interestingly, Harry Reich, who performed the first laparoscopic hysterectomy, also agreed that ‘evidence-based studies support the use of vaginal hysterectomy if possible over laparoscopic and abdominal hysterectomy’.4 We, therefore, support Ray Garry’s opinion that the optimum approach is the ‘one that can be performed with the greatest safety and produce the greatest relief of symptoms and improvement in quality of life in the most cost-effective manner’.1

Yet, despite the well-documented superiority of VH,3 most gynaecologists still prefer the abdominal route for removal of benign large uteri >12 weeks. Gonadotrophin releasing hormone (GnRH) agonists can reduce uterine bulk by up to 60% and was initially used to convert a midline incision to Pfannenstiel in TAH. The conversion of an abdominal to a potential VH by uterine size reduction would prove advantageous and Stovall et al5 was able to achieve an 80% VH rate after medically debulking uteri between 14–18 weeks with GnRH agonists. In this respect, we would like to share the results from a small case series of 10 women with uteri size >12 weeks who successfully underwent VH (mainly for menorrhagia) following preoperative treatment with GnRH agonists. A group of women who underwent TAH for similar indication and having similar uterine size served as control. Both groups had comparable subjective preoperative uterine bulk (median for VH 16 weeks), uterine weight at histology (median: 580 versus 609 g) and body mass index (> 0.05). The median duration of surgery (144.3 versus 85 minutes) and estimated blood loss (690 versus 340 mls) were significantly higher (both < 0.05) in the vaginal compared with abdominal hysterectomy group, although this was skewed by an outlier in the VH group (whose uterus weighed 1200 g). Oral analgesia use and the length of impatient stay, however, were lower in the VH group (2.62 versus 3.5 days, < 0.05).

We are aware that many exceptional vaginal surgeons are able to remove large uteri vaginally even without the use of GnRH agonists. Our modest study simply seeks to suggest that in bulky uteri >12 weeks, medical debulking can convert an abdominal to a potentially safe VH, thus encouraging the ‘average’ gynaecologist to attempt the latter route.

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