The role of total vaginal hysterectomy versus total abdominal hysterectomy in surgical management of uterine myomas: A retrospective single center cohort study

The suitable choice of TVH showed shorter operating times, reduced blood loss and hospital stay as compared to TAH in our study population. Therefore, TVH could represent a suitable choice in selected postmenopausal women with enlarged uterine myoma, mobile uterus weighing between 250 and 300 g, performed by an experimented surgeon.

Hysterectomy classifies as the 2nd most frequently performed procedure after cesarean section worldwide in gynecologic surgery. [ 1 , 2 ] Most hysterectomies are carried out to treat symptomatic uterine fibroids. [ 3 ] However, when the uterus is significantly enlarged, especially due to large fibroids, vaginal or laparoscopic approaches are often shown not to be feasible. In such cases, the abdominal route is chosen, mainly when the uterine weight is >450 g. [ 4 ] However, after exploring AH prevalence over 10 years (i.e., with the number in each survey ranging from 220,302 in 2006 to 275,631 in 2016) in the United States, a slight decrease was seen from 21.4% in 2006 to 21.1% in 2016. [ 4 ] Fibroids are benign growths; without causing symptoms, sometimes, they may lead to different distressing symptoms. [ 5 ] Although total abdominal hysterectomy (TAH) has certain limitations, such as intra and postoperative complications or a prolonged recovery period, it is still often used, remaining an invasive surgical technique. [ 6 ] Different complications were achieved during AH such as infections, genitourinary or gastrointestinal tract injuries, bleeding, and nerve injury. Vaginal cuff dehiscence was more common after TAH (0.15%) than after total vaginal hysterectomy (TVH) (0.08%). [ 6 ] In contrast, minimally invasive gynecological surgery, like TVH, offered higher perspectives like reduced postoperative pain, minimal blood loss, and a scarless surgical approach in 60 cases compared to 39 cases of laparoscopic hysterectomies. [ 7 ] Therefore, in support of this approach, many surgeons now try to perform “volume-reduction” techniques to facilitate TVH. Preoperative ultrasound control accurately diagnosed myoma and showed a high correlation with the final pathological findings. The superiority of achieving an ultrasound prior to surgery includes ruling out the presence of an ovarian tumor, as these conditions are linked to a higher risk of complications. [ 8 ] The primary known factor influencing the choice of surgical approach is represented by uterine size. Traditionally, TVH has been considered the procedure of choice in women with mobile uteri weighing up to 280 g, in accordance with the recommendations of the International Society for Gynecologic Endoscopy. Myomatous uteri exceeding >280 g were generally considered a contraindication for VH. [ 9 ] Kovac and contributors have reversed the ratio and performed VH for the non-prolapsed uterus in 91.8% of cases (i.e., from a total of 407 patients). [ 10 ] However, the implementation of practice guidelines for selecting the route of hysterectomy may increase the proportion of VH, thereby reducing inconsistencies in healthcare delivery. [ 10 ] Nevertheless, effective debulking procedures, or myomectomy, uterine bisection, and morcellation, have been described as useful approaches for facilitating TVH in such cases. [ 11 ] More recently, some authors reported successful TVH on 128 women with uterine fibroids and uteri weighing ≥280 g. [ 12 ] Another study, achieved on 285 patients with a mean uterine weight of approximately 312 g, showed that concomitant adnexal surgery and the presence of a larger uterus were found to be significantly associated with the selection of AH. The same study sustains that, in women with uterine fibroids, abnormal uterine bleeding as an indication for hysterectomy was associated with a higher likelihood of undergoing VH rather than AH. [ 13 ] The study by Sahin on 241 consecutive VH was performed on 2 groups: a group with a uterine weight of 280 to 1150 g and a group with uterine weight of <280 g. The results of this study showed that longer operating time and higher intraoperative hemorrhage were seen more in uterine weights between 280 and 1150 g. [ 14 ] However, studies directly comparing TVH and TAH in women with uterine myoma and sizes up to 300 g still remain limited. The aim of the present study was to compare the outcomes of TVH and TAH for uterine myoma as a suitable choice in patients from our hospital population, with a uterus weight between 250 and 300 g.

Conceptualization: Mihnea Nicodin. Data curation: Lucian Cristian Petcu. Formal analysis: Lucian Cristian Petcu, Ovidiu Nicodin. Investigation: Laura Nicodin-Tigoianu, Anca Popescu, Cristian Delcea. Methodology: Mariam Dalaty, Diana Badiu. Resources: Mihnea Nicodin, Ovidiu Nicodin. Supervision: Ovidiu Nicodin, Nicolae Suciu. Validation: Laura Nicodin-Tigoianu, Anca Popescu, Mariam Dalaty. Writing – original draft: Diana Badiu, Cristian Delcea. Writing – review & editing: Mihnea Nicodin, Nicolae Suciu.

A total of 140 patients were included in this retrospective, single-center cohort study conducted over a 4-year period, from June 1, 2020, to May 30, 2024. The study included patients scheduled to undergo hysterectomy with bilateral adnexectomy for an enlarged myomatous uterus at the Department of Gynecology, “Carol Davila” Central Military Emergency University Hospital, Bucharest, a tertiary center from Romania. Patients were divided into 2 groups according to the surgical approach: TVH group (n = 70) and TAH group (n = 70). The exclusion criteria were patients admitted for indications such as adenomyosis, uterine prolapse, chronic pelvic pain, cervical dysplasia, or malignancy; patients having a uterus 300 g with >3 myomas, or myomas > 6 cm, and patients aged 60, with a body mass index (BMI) 38, with a previously VH or AH history. All patients who fulfilled the predefined inclusion criteria (i.e., patients aged between 40 and 60 years, in a postmenopausal state, with uterine myomas with no >3 myomas and a maximum 6 cm diameter, and a uterus weighing between 250 and 300 g) were included in the study. The inclusion criteria for TVH were a mobile uterus, in which approximately 10% of patients were nulliparous, a limited history of previous surgical interventions, and an adequate vaginal length and width. The following variables were recorded: age, uterine weight, BMI, parity, medical history, and previous surgical history. Our primary outcome was defined by operative time, intraoperative blood loss, and hospital stay. Our secondary outcome was defined by intra and postoperative complications and adhesions, considering the timing and method of assessment. The diagnosis of uterine myoma was achieved preoperatively based on clinical symptomatology and transvaginal ultrasound. However, all patients underwent a systematic preoperative endometrial biopsy to exclude invasive pathology. This approach is particularly important before hysterectomy, as techniques to reduce uterine size, such as hemisection, tactical myomectomy, or morcellation, may be required during TVH. Histopathological confirmation of uterine myoma was obtained postoperatively from thectomy specimen, in accordance with our hospital protocol. A preoperative pelvic ultrasound examination was performed 1 day before surgery to assess the number, location, and diameter of the myomas. The presence and extent of pelvic adhesions were assessed intraoperatively. A urinary catheter was inserted preoperatively in all patients, and none of the patients received gonadotropin-releasing hormone (GnRH) agonist therapy before surgery. All patients received prophylactic intravenous cephalosporin antibiotic therapy prior to the procedure. All surgeries were performed by the 1st author, who has experience of >30 VHs/yr. Furthermore, the indications for conversion from TVH to TAH included massive hemorrhage, extensive pelvic adhesions, injury to adjacent organs or other surrounding structures, and tubal pathology. The surgical techniques used for TVH and TAH in our hospital are described below. The patient was placed in the dorsal lithotomy position. A thorough pelvic examination was performed under anesthesia to confirm the feasibility of the vaginal approach to hysterectomy, with particular attention to the pelvic arch and vaginal caliber. The cervix was then grasped with 2 Tirreballe clamps to provide adequate traction, and the cervicovaginal junction was identified. By using 20 to 50 mL of saline solution in the cervical region, hydrodissection was achieved. The anterior vaginal wall was subsequently incised through its full thickness, then retracted, allowing the bladder to be displaced caudally. Once the anterior peritoneal fold was identified, it was grasped, elevated, and incised. The posterior vaginal edge was grasped and dissected until the posterior peritoneal fold was reached. The uterosacral ligament was then clamped, sectioned, and ligated, followed by the cardinal ligament, which was managed in the same manner. In most cases, both ligaments were clamped and ligated together on each side. The same procedure was subsequently performed on the contralateral side. When anterior peritoneal access was not feasible because of abnormal vesicouterine adhesions, the inferior uterine pedicles were clamped, sectioned, and ligated. The next set of pedicles was then similarly clamped, sectioned, and ligated to facilitate further mobilization of the uterus. The uterine vessels were then identified between the anterior and posterior peritoneal reflections and subsequently sectioned and transfixion-ligated. Progressive bilateral clamping of the uterine arteries was performed, and once adequate vascular control had been achieved, the uterine fundus was localized and grasped with a traction clamp. The utero-ovarian vessels, fallopian tubes, and round ligaments were then double-clamped and ligated, thereby achieving complete detachment of the uterus and completion of the hysterectomy. Following removal of the uterus, a routine inspection of the operative field was performed. A right-angle or Breisky retractor was then inserted laterally into the peritoneal cavity to improve visualization. Once the fallopian tubes and ovaries were identified, the adnexa were gently grasped and placed under gentle traction. Subsequently, a Heaney clamp was positioned lateral to the utero-ovarian pedicle and advanced superiorly to clamp the infundibulopelvic ligament and secure the gonadal vessels. A resorbable suture was then placed around the Heaney clamp, and the pedicle was doubly clamped and ligated to ensure secure hemostasis. Hemostasis was systematically assessed, beginning at the cervicovaginal pedicle. The retroperitoneal space was subsequently obliterated by suturing the anterior peritoneal fold to the anterior vaginal cuff and the posterior peritoneum to the posterior vaginal cuff. Finally, the vaginal vault was closed by approximating the anterior and posterior vaginal walls. A peritoneal drain was placed in both groups in accordance with our department’s standard surgical protocol. In the TVH group, the drain was introduced through the vaginal cuff into the peritoneal cavity, whereas in the TAH group, it was inserted through the abdominal route. The drains were placed to prevent the accumulation of blood and fluid and to reduce the risk of postoperative complications, like infection, fever, and severe pain. In both groups, the drain was routinely removed 48 hours after surgery. [ 15 ] Vaginal packing with povidone-iodine-impregnated gauze was performed to facilitate monitoring for postoperative bleeding. Cystourethroscopy was performed at the end of the procedure when inadvertent bladder injury was suspected, to confirm the integrity of the bladder and ureters. The patient was placed in Trendelenburg position, following preparation and draping of the surgical field. The abdominal approach was performed through either a Pfannenstiel or Maylard incision. In cases involving a Maylard incision, the aponeurosis was sectioned, followed by division of the rectus abdominis muscles. The inferior epigastric vessels were then clamped, sectioned, and ligated. The median umbilical ligament was clamped, sectioned, and ligated, with its lower portion subsequently used to facilitate exposure of the operative field. A systematic inspection of the peritoneal cavity was then performed, with adhesiolysis carried out when necessary. Surgical exposure was optimized using abdominal drapes and an automatic self-retaining retractor. To provide adequate uterine traction, 2 forceps were applied bilaterally to the uterine horns, encompassing the insertions of the round ligaments, utero-ovarian ligaments, and fallopian tubes. The round ligaments were then bilaterally clamped, sectioned, and ligated. Subsequently, the posterior leaf of the broad ligament was opened to facilitate retroperitoneal access to the lumbo-ovarian ligament. The pelvic ureter was identified, and an opening was created inferior to the lumbo-ovarian ligament. The infundibulopelvic ligament was then clamped, sectioned, and double ligated. The sectioning of the leaves of the broad ligament was continued toward the uterus, followed by detachment of the appendix. Bilateral adnexectomy was subsequently performed, after which the utero-ovarian ligaments were bilaterally clamped, sectioned, and ligated. Operative time was defined as the interval from the initial surgical incision to completion of the procedure. Intraoperative blood loss was estimated by the surgical nurse using the same method for both surgical approaches to ensure consistency and minimize interobserver measurement differences. Blood loss was assessed based on the number of soaked mops, with a quarter-soaked mop corresponding to approximately 20 mL of blood, a half-soaked mop to 40 mL, and a fully soaked mop to 80 mL. The surgical specimen was weighed immediately after the procedure. Hospital stay was defined as the total number of days the patient remained hospitalized. [ 16 ] The next steps after TVH depended on the size and features of the uterine mass. We used either uterine hemisection, tactical myomectomy, or morcellation for most of the cases, which are described below. Uterine hemisection involves sagittal division of the uterus, beginning at the cervix and proceeding in a cranial direction. Tactical myomectomy was also performed, particularly when centrally located nodules were identified within the uterine mass. The nodules were grasped and removed, either digitally, with dissecting forceps, or during intramyometrial reduction or morcellation. Morcellation, an additional technique, was also used for the sequential excision of myometrial fragments. All patients received standardized postoperative analgesia according to standard protocol. Pain management consisted of 2 intravenous doses of meperidine (50 mg each), administered at 4-hour intervals, followed by acetaminophen (325 mg) every 6 hours. Patients were discharged once adequate pain control was achieved with oral analgesics alone, a soft diet was tolerated, spontaneous urination was restored, and normal bowel function had resumed. Intraoperative complications were categorized as follows: depolishing of large intestinal loop and inadvertent cystotomy–cystorrhaphy. Postoperative complications were recorded and classified according to type, including urinary tract infection (UTI), wound seroma, dynamic ileus, and secondary anemia. All patients were scheduled for a follow-up visit 2 weeks after surgery. The final histopathological findings of the surgical specimens were subsequently compared with the preoperative ultrasound findings. Statistical analyses were performed using IBM SPSS Statistics, version 23 (IBM Corp., Armonk). Continuous variables were summarized using appropriate measures of central tendency and dispersion, as presented in Table 1 , whereas categorical variables were expressed as percentages for each category (Table 2 ). Measures of central tendency and dispersion for continuous variables in TVH and TAH groups. BMI = body mass index, IQR = interquartile range, SD = standard deviation, TAH = total abdominal hysterectomy, TVH = total vaginal hysterectomy. Based on independent samples t test. Based on Mann–Whitney U test. Distribution of percentages for categorical variables in patients undergoing TVH and TAH. TAH = total abdominal hysterectomy, TVH = total vaginal hysterectomy. The normality of continuous variables was assessed using the Kolmogorov–Smirnov test. For hypothesis testing, the independent samples t test, Mann–Whitney U test, and median test were applied, with the statistical significance level (α) set at 0.05. The Kolmogorov–Smirnov test indicated that the assumption of normality was satisfied only for age ( P  > .05), whereas this assumption was violated for most continuous variables across the study ( P  < .05). Accordingly, nonparametric methods, such as the Mann–Whitney U test and median test, were used for the corresponding analyses. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of “Carol Davila” Central Military Emergency Hospital, Bucharest, Romania (Ref. No. 773/March 11, 2025). All participants who agreed to participate in the study provided written informed consent after being fully informed of associated risks and limitations.

A total of 140 patients underwent either TVH or TAH. The common indication for both groups was uterine myoma and a uterus weighing between 250 and 300 g. TVH with bilateral adnexectomy was performed in 68 (97.14%) patients, and TAH with bilateral adnexectomy was performed in 69 (98.57%) patients. From each group, only 2 patients (2.86%) had unilateral adnexectomy, which did not affect our results. The other patient had previously experienced adnexectomy. Our clinical justification for using bilateral adnexectomy in postmenopausal women was based on the definitive treatment of symptomatic gynecological diseases and significant risk reduction for future malignancy. The main demographic and clinical characteristics of patients undergoing TVH or TAH, summarized using measures of central tendency and dispersion for continuous variables, are presented in Table 1 . However, no statistically significant difference was observed in mean age between the TVH group (49.60 ± 4.24 years) and the TAH group (50.29 ± 4.57 years; t  = −0.921, df = 138, P  = .359 > α = 0.05). For uterine weight variable, the nonparametric Mann–Whitney U test showed no statistically significant differences between TVH group (average rank = 68.35) and TAH group (average rank = 72.65: U  = 2299.50, z  = −0.629, P  = .529 > α = 0.05). The median test sustained the same results (chi-Square = 0.457, df = 1, P  = .499 > α = 0.05). The nonparametric Mann–Whitney U test for BMI variable revealed also no statistically significant differences between TVH group (average rank = 74.91) and TAH group (average rank = 66.09: U  = 2141.50, z  = −1.286, P  = .198 > α = 0.05). The median test manifests the same outcome (chi-Square = 1.029, df = 1, P  = .310 > α = 0.05). The same values were acquired for the parity, with no statistically significant differences between TVH group (average rank = 71.26) and TAH group (average rank = 69.74: U  = 2397.00, z  = −0.233, P  = .815 > α = 0.05), the Median test being in accordance with these features (chi-square = 0.598, df = 1, P  = .439 > α = 0.05). Interestingly, there were statistically significant differences for the operative time, when TVH group (average rank = 49.50) was compared to TAH group (average rank = 91.50: U  = 980.00, z  = −6.129, P  < .001 < α = 0.05). The Median test established the same conclusion (chi-square = 20.833, df = 1, P  < .001 < α = 0.05). However, by using TVH, it was lowering surgical risks, decreasing anesthesia exposure, and accelerating patient recovery. For the intraoperative blood loss variable, the Mann–Whitney U test revealed statistically significant differences between TVH group (average rank = 36.02) and TAH group (average rank = 104.98: U  = 36.50, z  = −10.060, P  < .001 < α = 0.05), reinforced by the median test (chi-square = 117.029, df = 1, P  < .001 < α = 0.05). Our results showed a lowers need for blood transfusions, maintaining a clearer surgical field for safer tissue dissection in TVH cases. For hospital stay variable, statistically significant differences were also observed, with shorter hospital stays in TVH group (average rank = 43.13) compared to TAH group (average rank = 97.87: U  = 534.00, z  = −8.210, P  < .001 < α = 0.05). The Median test showed similar results (chi-square = 56.000, df = 1, P  < .001 < α = 0.05), which sustain a safe recovery and early mobilization for TVH group. Medical history was slightly more frequent in TAH group than in TVH group (50.00% vs 47.14%). Similarly, a history of previous surgical interventions was reported in 50.00% of patients in TAH group, compared with 38.57% in TVH group. Intraoperative complications were reported in 2.86% of patients in TAH group, comprising 1 case with depolishing of a large intestinal loop and 1 case of inadvertent cystotomy– cystorrhaphy. No intraoperative complications were observed in TVH group. Postoperative complications were also slightly more frequent in TAH group than in TVH group (11.44% vs 4.29%). In TVH group, these included UTI in 1 patient and secondary anemia in 2 patients. In TAH group, postoperative complications comprised UTI in 2 patients, wound seroma in 2 patients, dynamic ileus in 1 patient, and secondary anemia in 3 patients. There was no statistically significant difference between the proportion of patients with medical history in TVH group ( P  = .4714) compared with the proportion of patients with postoperative complications in TAH group ( P  = .5000): P -diff = −.0286, z  = −0.3382, P value = .7352 > .05, 95% confidence interval for P -diff: −.1941 to .1369 (Table 2 ). All planned TVH procedures were successfully completed vaginally, with no cases requiring conversion to laparotomy. Adhesions were more frequently observed in TAH group than in TVH group (32.86% vs 20.00%). In TVH group, uterine hemisection (Fig. 1 ), tactical myomectomy, or morcellation was required in most cases (n = 55, 78.57%) to achieve adequate reduction of uterine-size. In contrast, intramyometrial reduction or morcellation following cervical amputation was performed in only a minority of cases (n = 15, 21.42%; Fig. 2 ). Gross anatomy of the uterus and cervix after uterine hemisection. Gross anatomy of the uterus with multiple myomas after morcellation.

In our study population, TVH group was consisted from equal number of patients as in TAH group, considering the fact that our department specializes in gynecological oncology, being the only 1 in Romania, in which the number of patients for selecting TVH were higher. We have chosen to use bilateral adnexectomy in all patients, regarding to be a procedure with substantial benefits for malignancy prevention. Our clinical decision was based on a balance between eradicating malignancy risks and avoiding long-term, chronic conditions. However, the groups were similar in terms of mean age, uterine weight, BMI, parity, and rates of intra or postoperative complications. Similar findings were reported by the study of Benassi et al. [ 17 ] Two important key factors influence the role of TVH in women with enlarged uterine myoma, uterine mobility and patient surgical history. [ 18 ] More recently, common contraindications for TVH, such as uterine volumes, nulliparity, or previous laparotomy, have been related as rare. [ 19 ] Unger showed that vaginal removal of enlarged uteri (i.e., until 700 g), compared to those under 200 g, is not associated with increased complications or longer hospital stays, but does result in longer operative times, which increase proportionally with uterine weight. [ 20 ] Magos et al [ 21 ] removed even larger uteri (i.e., between 380 and 1100 g) by employing different uterine reduction volume techniques for TVH. Interestingly, Vercellini et al found that TVH was feasible in 80% of patients treated with GnRH agonists compared to only 16% of untreated patients. [ 22 ] However, another study reported that the preoperative use of GnRH agonists in women with uterine fibroids undergoing hysterectomy may not be cost-effective, as these agents increase overall treatment costs, despite their ability to substantially reduce uterine volume and, consequently, surgical morbidity. [ 23 ] In the current series, no patients received preoperative GnRH agonist therapy before TAH or TVH techniques. Uterine size can be estimated preoperatively via ultrasonography to guide surgical approach decisions. Sheth and Shah performed preoperative sonographic assessment of uterine volume in 380 nonpregnant women with benign uterine conditions and reported that uterine volumes exceeding 300 cm 3 were associated with greater technical difficulty, and therefore, TVH should be attempted with caution in these cases. [ 24 ] However, in our study, it was seen a great correlation between preoperatively ultrasonography findings and final histopathological outcomes. When VH (n = 120) was compared with laparoscopically assisted VH (n = 39) for large leiomyomas, Litwińska et al reported that the main advantages of the abdominal approach included the ability to perform comprehensive abdominopelvic exploration and adnexectomy, with surgical expertise also playing an important role in determining the feasibility of the procedure. However, their findings demonstrated that VH was associated with shorter operative time and reduced intraoperative blood loss, supporting its use as an appropriate route when minimizing the duration of surgery and anesthesia as a priority. [ 25 ] Another study comparing abdominal, vaginal, and laparoscopic-assisted hysterectomy reported that VH was more advantageous in patients with a uterus <12 weeks in size. In contrast, laparoscopic hysterectomy appeared to be more suitable for patients with large uterine fibroids, ovarian abnormalities, or endometriosis. [ 26 ] The study by Kim et al, which compared patients undergoing TVH or total laparoscopic hysterectomy for large uteri weighing >300 g, demonstrated that, when performed by surgeons experienced, TVH should be preferentially considered over total laparoscopic hysterectomy for a better management. [ 27 ] Furthermore, the review by Sonkusare and Dixit sustained that non-descent VH offers several advantages over total laparoscopic hysterectomy, including a scarless approach, shorter operative time, minimal blood loss, and fewer complications. Therefore, the choice of hysterectomy route should be individualized according to the underlying pathology and uterine size, the surgeon’s experience, the technological resources available, and the preferences of both the patient and the surgeon. [ 28 ] Our study showed that TVH was associated with significantly shorter operative times, lower intraoperative blood loss, and reduced hospital stays compared with TAH. These findings are consistent with those reported by Goswami et al, who compared VH with AH and found that VH was associated with shorter operative times, and faster postoperative recovery. [ 29 ] Similarly, our results showed a higher incidence of postoperative complications in TAH group compared with TVH group, further supporting the potential postoperative advantages of the vaginal approach. However, our previous studies on both TVH and TAH on uterine prolapse and adenomyosis showed that TVH represented a feasible surgical technique, with similar features as minimally invasive surgical technique, the present research representing a continuation of the other 2. [ 30 , 31 ] In our study, intraoperative blood loss was estimated using the number of blood-soaked mops, with the same method applied to both surgical approaches, TVH and TAH. Estimated blood loss is a standard component of the medical record and represents an important parameter for clinical decision-making and the assessment of surgical outcomes. Both increased blood loss and the need for intraoperative blood transfusion have been associated with increased postoperative morbidity and mortality. Failure to recognize substantial blood loss may result in inadequate tissue oxygen delivery, whereas overestimation may lead to unnecessary blood product transfusion. Nevertheless, accurate estimation of intraoperative blood loss remains challenging in various clinical settings, and the most appropriate estimation method depends on the specific surgical context. [ 32 ] A study involving 105 patients with bulky uterine fibroids, of whom 56 underwent VH and 49 underwent total laparoscopic hysterectomy, included patients with estimated uterine volumes ranging from 280 to 1200 cm 3 . The authors demonstrated that VH was a safe and feasible approach and suggested that it may represent a more suitable value-based surgical option compared with total laparoscopic hysterectomy. However, the study sustains the fact that gynecologists should performed vaginally the technique, differentiating themselves from general or laparoscopic surgeons. [ 30 ] Another study achieved on 60 patients with dysfunctional uterine bleeding, adenomyosis or leiomyoma with a uterus <12 weeks, included 2 groups: 30 patients underwent VH and 30 patients underwent AH. The results showed that operative time, per operative blood loss, immediate postoperative pain, operation costs, hospital stays, and number of suture materials needed for intervention were lower in VH group. Further, the authors indicated that VH should be the 1st choice when considers a hysterectomy. [ 33 ] Another study involving 100 patients with uterine sizes ranging from 6 to 14 weeks of gestation demonstrated that non-descent VH represents a suitable alternative to AH in patients with benign uterine pathology, a uterine size of <14 weeks, and a mobile uterus. [ 34 ] Other study used the same measurements in 60 patients with TVH and TAH techniques. [ 35 ] Bharatnur’s results made a rough estimation of blood loss in 25 patients with TVH and 25 patients of TAH, by noting the number of mops used during surgery. [ 36 ] However, another study reported that the clinical estimation of blood loss using the gravimetric method showed good agreement with the actual blood volume estimation. In this method, the dry weight of standard surgical swabs and abdominal pack was subtracted from their weight after soaking, using a calibrated weighing device, with the resulting value expressed in grams and converted to milliliters based on the Rain’s factor, whereby 1 g of gauze is considered equivalent to 1 mL of blood. However, the standard measurement of the surgical swab was showed to be 10.6 by 10.6 cm and the standard abdominal pack was 30.48 by 30.48 cm. These findings may provide a practical and reliable approach for estimating intraoperative blood loss during major surgical procedures and may facilitate the early recognition and prompt management of significant intraoperative hemorrhage. [ 37 ] Another important factor influencing the role of TVH is the surgeon’s proficiency in performing reduction-size technique. In our study, endometrial biopsy was performed preoperatively in all patients to exclude invasive conditions, including uterine sarcoma. This precaution is especially important before performing either surgical technique, as various uterine reduction-size procedures may be required, including hemisection, tactical myomectomy, or morcellation. Liu et al demonstrated that endometrial biopsy has relatively high sensitivity for detecting uterine sarcomas, while increasing age and postmenopausal status were identified as nonspecific risk factors for this malignancy. [ 38 ] Strategies aimed at allowing surgeons to continue offering minimally invasive procedures while minimizing the potential risk of disseminating an occult malignancy should focus on refining reduction in uterine size techniques. In the absence of reliable evidence, however, recommendations regarding the safety of these techniques remain premature, particularly considering the well-established benefits of minimally invasive surgery in terms of quality of life. [ 38 ] Overall, the reported incidence of unexpected malignancy, including endometrial carcinoma and uterine sarcoma, in presumed leiomyomas following hysterectomy, with or without morcellation, ranges from 0.00% to 0.91%. In a population-based analysis evaluating the risk of occult malignancy in morcellated uterine specimens, Wright et al reported a 35-fold higher risk of uterine cancer among women aged above 60 years, compared with those younger than 40 years. [ 39 ] However, these findings suggest that the dissemination of occult malignant tissue represents a major potential risk associated with reduction in uterine-size techniques, including hemisection, tactical myomectomy, and morcellation, and may ultimately result in less favorable clinical outcomes. [ 40 ] Because vaginal morcellation of an enlarged uterus may be time-consuming, it is generally considered a safe and effective technique. Other uterine reduction-size procedures, including uterine bisection, [ 41 ] coring, [ 42 ] the Pryor procedure, [ 43 ] and Lash technique ,[ 44 ] have also demonstrated favorable outcomes. Several studies have confirmed the effectiveness of vaginal morcellation techniques for the removal of large myomatous uteri through the vaginal route. [ 45 ] When performed by an experienced vaginal surgeon, these techniques may allow the successful removal of uteri corresponding to a gestational size of up to 20 weeks. [ 46 ] In our study, uterine hemisection, tactical myomectomy, and morcellation were used in the majority of patients in TVH group to facilitate reduction in uterine-size. Hysterectomies initiated vaginally may require conversion to abdominal route in approximately 1% to 4.2% of cases. [ 47 ] However, in the present study, all TVH were successfully completed, and no intra or postoperative complications necessitating immediate or delayed hospital readmission were observed. Several strengths of our study should be highlighted. First, the study population was relatively homogeneous, and the consistency of the surgical techniques was ensured by all procedures being performed by the same surgeon. We provide a detailed description of the TVH technique to facilitate its reproducibility in clinical practice, highlighting its potential economic advantages. Another important strength is that none of the patients undergoing planned TVH required conversion to TAH, demonstrating the feasibility of the vaginal approach in appropriately selected patients. Finally, in accordance with current recommendations, our protocol included a preoperative endometrial biopsy, which allowed the exclusion of suspected occult malignancy before hysterectomy. Several limitations of our study should also be acknowledged. First, its retrospective, single-center, non-randomized design limits the generalizability of the findings and introduces the potential for selection bias in determining the route of hysterectomy. In addition, the relatively short postoperative follow-up period does not allow for assessment of long-term outcomes. Surgeon-related bias may also have influenced the selection of surgical approach and the intraoperative management of individual cases. Furthermore, the applicability of the TVH approach may be limited in patients with specific clinical or anatomical conditions, particularly those with extensive pelvic adhesions resulting from previous surgical interventions. The relatively small number of patients with a history of previous surgery and extensive adhesions also limits the ability to draw definitive conclusions regarding the application of TVH in this particular group.