Archives of

Arch Gynecol Obstet (1992) 251:87-91 Gynecology

and Obstetrics
© Springer-Verlag 1992

Routine prophylactic oophorectomy at the time of

vaginal hysterectomy in postmenopausal women
S. Sheth and A. Malpani
Department of Obstetrics and Gynecology,K. E. M. Hospital, Bombay, India
Received September 24, 1990/AcceptedNovember5, 1991

Summary. Our experience with the routine removal of ovaries at the time of
vaginal hysterectomy for 150 postmenopausal women is presented. The records
of these women were compared with 200 women who underwent simple vaginal
hysterectomy. The additional step of vaginal oophorectomy did not add to the
morbidity of vaginal hysterectomy, and it is recommended that routine oophor-
ectomy be considered for postmenopausal women having a vaginal hyster-
ectomy.
Key words: Vaginal hysterectomy - Vaginal oophorectomy - Vaginal salpingo-
oophorectomy - Postmenopausal hysterectomy

Introduction

Routine prophylactic oophorectomy for postmenopausal patients at the time of

abdominal hysterectomy is standard practise today. While logic dictates that the
same guidelines should apply when doing vaginal hysterectomy for postmeno-
pausal patients, the majority of gynecologists do not do such prophylactic
oophorectomies when doing that operation because the surgeon is apprehensive
about technical difficulties. We now present results which demonstrate the
feasibility of routine oophorectomy at the time of vaginal hysterectomy in
postmenopausal women.

Materials and methods

Of a total of 740 vaginal hysterectomieswith oophorectomiesperformed by the first author in his

private practice over the last ten years (Sheth 1990), 150 patients were postmenopausal. The records
of these postmenopausal patients (Group 1) were reviewed, and compared with the records of 200
premenopausal patients who had undergone a vaginal hysterectomywithout oophorectomy by the

Offprint requests to: Dr. S. Sheth, 2/2 Navjivan Society, LamingtonRoad, Bombay 400008, India
88 S. Sheth and A. Malpani

same surgeon (Group 2) during the same period. Special attention was paid to the operative time,
intraoperative complications, technical difficulties, length of hospital stay and postoperative mor-
bidity.
Of the 150 patients in group 1, 42 had a vaginal hysterectomy with bilateral salpingo-
oophorectomy; 44 had a bilateral oophorectomy; 31 had a vaginal hysterectomy and bilateral
salpingo-oophorectomy combined with anterior colporrhaphy and posterior colpoperineorrhaphy
for repair of vaginal prolapse; and 28 patients had a salpingo-oophorectomy on one side, and an
oophorectomy on the other. It was not possible to remove both the ovaries of three patients, and
one ovary of two patients.

Results

It was possible to remove both the ovaries in 145 of the 150 postmenopausal
women (96.67%). The additional operative time required to remove the ovaries
vaginally varied from 7 to 30 rain (mean: 15 min). The length of postoperative
hospital stay varied from 5 days to 8 days, and was similar in both groups. Of the
technical difficulties encountered during vaginal oophorectomy, there were five
instances where the tube was torn, and seven cases where the ovary was torn.
However, this did not cause any problems during the surgery. Small hematomas
formed in the infundibulopelvic ligament in six patients, but these were small

Table 1. Details of complications

Group 1 Group 2
patients patients

Pyrexia 9 10
Urinary tract infection 40 42
Wound sepsis 3 2
Reactionary hemorrhage 2 2
Blood stained vaginal discharge 78 81
Granulation tissue at vault 12 12
Fallopian tube prolapse 6 20
Laparotomy 0 0
Trauma to bladder 0 0
Trauma to rectum 0 0
Blood transfusion 18 7

Table 2. Time taken for surgery

Group 1 Group 2

Number of minutes
Less than 30 0 24
30-45 15 68
45-60 46 82
61-90 77 20
91-120 10 6
120-150 2 0
Routine vaginaloophorectomy 89

Table 3. Postoperativehospitalstay in days

Group 1 Group 2
Number of days
3-4 12 22
5-6 98 132
7-10 31 36
10-15 9 10

and self-limited, and did not require laparotomy or transfusion. There were no
major complications in either of the two groups of patients, with no instances of
death, ureteral or bowel injury, or postoperative haemorrhage.
Details of the comparison are presented in Tables 1, 2 and 3.

Technique

When removing the ovaries vaginally during a vaginal hysterectomy, the sur-
geon has the choice of performing either a vaginal oophorectomy or a salpingo-
oophorectomy. Wright (1974) successfully performed vaginal oophorectomy in
all of a series of 60 patients and felt that vaginal oophorectomy was technically
easier as compared to vaginal salpingo-oophorectomy, because access to the
mesovarium was easier than access to the infundibulopelvic ligament by the
vaginal route.
The choice between the two can only be made after the uterus is completely
severed from all its pedicles on one side. It then hinges on the contralateral
upper pedicle, which consists of the round ligament, utero-ovarian ligament,
and the fallopian tube. In order to provide easy access to the infundibulopelvic
ligament, the round ligament must now be separately clamped, cut and ligated.
The uterus with the tube, ovary and mesovarium is then left hanging on the
support of the infundibulopelvic ligament only.
If salpingo-oophorectomy appears possible, based on accessibility of the
infundibulopelvic ligament, a clamp is applied to that ligament. Gentleness at
this time will prevent tearing and bleeding. Occasionally, more than one clamp
may be required to cover the entire ligament. The infundibulopelvic ligament is
then transfixed, and doubly ligated with 1-0 Vicryl. The other ovary is then
removed in the same manner. Retraction of the bladder and vaginal walls with
Deaver's and Jayle's retractors respectively provides the needed exposure. In
case a salpingo-oophorectomy appears difficult - because of limited space or
because of a long uteroovarian ligament - a simple oophorectomy may be
performed, by clamping, cutting and ligating the mesovarium. The fallopian
tube is then brought down to cover the raw area. Closure of the peritoneum is
then performed in the routine fashion. (A videotape (VHS-PAL) of the
operative technique is avilable on request from the first author).
Certain prerequisites which should be satisfied in order to safely perform
vaginal oophorectomy include (1) normal tubes and ovaries, and (2) easy
90 s. Sheth and A. Malpani

accessibility and free mobility of the ovaries, which can be brought medially into
the operative field when held with a Babcock forceps. Attention to positioning
of the retractors and adequate lighting (often best provided with a fibre-optic
light source and cable) help considerably.
Contraindications to vaginal oophorectomy include (1) tuboovarian adhe-
sions (2) high, immobile, atrophic ovaries and (3) contraindications to hormone
replacement therapy.
Special attention to the following points will help to simplify the procedure.
(1) The round ligament should be clamped and cut prior to attempting vaginal
salpingo-oophorectomy. (2) A specially designed clamp, which has a terminal
one inch curve, helps in ensuring that the pedicle is securely grasped, and also
provides better visualisation when placing the ligature. Finally, (3) better
exposure is provided by placing the patient in a steep Trendelenburg position,
and by using a long roller gauze pack to keep the intestines and omentum away
from the operative field.

Discussion

Prophylactic oophorectomy at the time of abdominal hysterectomy for post-

menopausal women is standard practice today to prevent the patient from later
developing ovarian cancer. Oram and Jacobs (1987) concluded that if prophy-
lactic oophorectomy were routinely performed, seven percent of cancers of the
ovary could be prevented. A survey of the fellows and members of the Royal
College of Obstetricians and Gynecologists regarding the practice of prophylac-
tic oophorectomy demonstrated that the overwhelming majority (85.3%) would
perform the procedure in postmenopausal women at the time of abdominal
hysterectomy (Jacobs 1989). Studd (1989) recommends prophylactic oophorec-
tomy at abdominal hysterectomy in all women over the age of 40 years.
The same logic should be applied at the time of vaginal hysterectomy in
postmenopausal women and the decision to remove the ovaries should not be
based upon the route of the hysterectomy. If removal of the ovaries is indicated
at the time of abdominal hysterectomy in postmenopausal women, it is indicated
at the time of vaginal hysterectomy as well. Unfortunately, however, few
gynecologists apply this reasoning to routinely remove the ovaries during
vaginal hysterectomy for postmenopausal women. This inconsistency in practice
should be resolved.
The primary reason that vaginal oophorectomy is not performed routinely at
the time of vaginal hysterectomy is because of the surgeon's apprehension
regarding the technical feasibility of this step. This diffidence leads to an inade-
quate standard of care - as exemplified by the occasional patient who develops
ovarian cancer after vaginal hysterectomy (Bloom 1962; Scottolini 1986) simply
because the ovaries were not removed at the time of surgery. It may also lead the
surgeon to opt for the abdominal route when doing a hysterectomy for a
postmenopausal patient, simply in order to be able to take out her ovaries, while
the patient may be better served by a vaginal procedure that actually carries alower
morbidity than the abdominal operation (Dicker 1982).
Routine vaginal oophorectomy 91

Such a p p r e h e n s i o n is u n f o u n d e d and the surgeon who can r e m o v e the uterus

c o m f o r t a b l y t h r o u g h the vagina should have little difficulty in performing
vaginal o o p h o r e c t o m y or salpingo-oophorectomy. Experience always has to
begin s o m e w h e r e , and p o s t m e n o p a u s a l w o m e n with third degree uterine pro-
lapse, where the ovaries are easily accessible, are excellent first candidates for
this p r o c e d u r e .
Prophylactic o o p h o r e c t o m y is clearly indicated w h e n doing a h y s t e r e c t o m y
for p o s t m e n o p a u s a l w o m e n whether the surgery is a b d o m i n a l or vaginal
(Sheth). W e have clearly shown that vaginal o o p h o r e c t o m y is technically
possible, and can be safely performed when doing vaginal h y s t e r e c t o m y ,
without significantly increasing morbidity. In a series of 77 patients, C a p e n
(1983) f o u n d that 6 0 - 7 0 % of ovaries could be r e m o v e d without m u c h difficulty
at the time of vaginal hysterectomy. It is our opinion, that just as a supracervial
abdominal h y s t e r e c t o m y is a subtotal operation, and has limited applicability in
gynecologic surgery today, similarly, performing a simple vaginal h y s t e r e c t o m y
for a p o s t m e n o p a u s a l w o m a n , without removing her ovaries, is an incomplete
operation.

Acknowledgement. The authors would like to acknowledge the editorial assistance of Rosalyn Uhrig
Vu in the preparation of this manuscript.

References

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