ABSTRACT

Objective

Laparoscopic hysterectomy is the vaginal removal of the uterus with laparoscopic asistance. After hysterectomy, vaginbal length may be shortened by cuff suturing, resulting in outcomes such as dyspareunia and sexual dysfunction. Hysterectomy may also affect women physically and psychologically, and lead to changes in sexual function. In patients planned to undergo hysterectomy; changes that may occur in sexual functions cause serious concerns during the pre- operative period. However, physicians often miss these important points and do not discuss these issues adequately with patients. In this prospective randomized study, we aimed to compare the effects of vaginal cuff closure techniques in laparoscopic hysterectomy on vaginal length (primary outcome) and women’s sexual function [secondary outcome, assessed by the Arizona Sexual Experience Scale (ASEX)].

Methods

Sixty-three patients who underwent laparoscopic hysterectomy in the clinic of gynecology and obstetrics Bolu Abant İzzet Baysal University Training and Research Hospital were included in this study. They were divided into two groups according to the vaginal cuff closure techniques during the total laparoscopic hysterectomy operation: those closed with laparoscopic suturing and vaginal suturing. Demographic data and pre-operative vaginal lengths of the patients were recorded in the pre-operative period. It was planned to measure vaginal lengths andevaluate sexual life functions 3 months after the hysterectomy operation. Vaginal length measurement was performed using a graduated metal ruler (Hegar bougie with scale) from the hymenal ring to the vaginal vault apex, with the patient in the lithotomy position and without anesthesia. At the same time, the sexual life functions of the patients were evaluated with the ASEX.

Results

Our study was conducted with a total of 63 patients, including 32 laparoscopic suturation patients and 31 vaginal suturation patients. When the average difference in vaginal length was examined in the patient group who underwent laparoscopic suturation, it was found to be 0.67±0.22 cm. When the average difference in vaginal length was examined in the patient group who underwent vaginal suturation, it was found to be 0.92±0.30 cm. When the vaginal lengths of the two groups were compared, a statistically significant difference wasdetected in vaginal suturing. Difference in the mean ASEX score in the surveys conducted in the pre-operative and post-operative periods in patients who underwent laparoscopic suturation; it was found to be 1.38±1.5. Difference in the mean ASEX score in the surveys conducted in the pre- operative and post-operative periods in patients who underwent vaginal suturation; 1.1±1.1 was detected. There was no statistically significant difference between the groups in terms of the difference between pre-op and post-operative measurements. This showed that the suturing technique in laparoscopic hysterectomy had no effect on the ASEX. There was no significant correlation between vaginal length difference and ASEX score difference and demographic data such as age, height, body mass index, smoking history, comorbidity history, and previous operation history proteinuria.

Conclusion

We found that laparoscopic vaginal cuff suturing shortens the vaginal length less and causes fewer complications. There was no statistically significant difference between the groups in terms of changes in ASEX scores (p=0.42). Mean operation time was significantly shorter in the laparoscopic group compared to the vaginal group (81.4±12.5 vs. 88.5±13.7 minutes, p=0.03). In terms of complications, vaginal vault hematoma occurred in 0 vs. 1 patient, infection in 2 vs. 4 patients, and dehiscence in 1 vs. 1 patient. Although the overall complication rate was numerically lower in the laparoscopic group (9.3% vs. 19.3%), the difference was not statistically significant (p=0.21). Since this was a single-center study with all procedures performed by a single surgeon, external validity may be limited. The findings should be generalized with caution to broader populations or different surgical settings. We believe that prospective, randomized studies with larger case series are needed to support our findings.

Introduction

Hysterectomy is defined as the surgical removal of the uterus using various approaches. Laparoscopic hysterectomy, in particular, involves the removal of the uterus through the vagina with laparoscopic assistance. It offers advantages such as shorter hospital stay, faster postoperative recovery, less postoperative pain, and better visualization of pelvic structures.

Following hysterectomy, anatomical changes such as vaginal shortening due to vaginal cuff closure can result in sexual dysfunction, including dyspareunia and decreased sexual satisfaction (1). In addition to structural changes, hysterectomy may impact female sexual function through physiological, hormonal, and psychological mechanisms. Physiologically, disruption of pelvic nerve supply and reduced pelvic blood flow may impair arousal and lubrication (2). Hysterectomy may also lead to hormonal imbalances, particularly when oophorectomy is performed or ovarian blood flow is disrupted, resulting in reduced estrogen and progesterone levels (3). Psychologically, changes in body image, mood, and perception of femininity can further contribute to sexual dysfunction. Body image has a determining effect on an individual’s eating behaviors, social anxiety levels, sexual behaviors, social relationships, and emotional states, in addition to their self-esteem (4).

Despite these concerns, the impact of hysterectomy on sexual function is often under-addressed during preoperative counseling. Furthermore, the surgical technique used for vaginal cuff closure-vaginal or laparoscopic-may influence postoperative outcomes including vaginal length and sexual function, yet few studies have directly compared these techniques.

In this prospective study, we aimed to compare the effects of two vaginal cuff closure techniques-laparoscopic versus vaginal-on postoperative vaginal length and female sexual function following laparoscopic hysterectomy. Sexual function was assessed using the Arizona Sexual Experience Scale (ASEX), a validated tool frequently used in gynecologic research.

Methods

This was a prospective clinical study conducted at Bolu Abant İzzet Baysal University Ethic Committee after obtaining ethics approval (decision no: 2021/104, date: 01.02.2023). All participants provided written informed consent. A total of 63 patients who underwent laparoscopic hysterectomy for benign gynecologic conditions were included. The vaginal cuff was closed using one of two techniques: laparoscopic intracorporeal suturing or vaginal suturing. Only patients operated on by a single experienced surgeon were included to minimize operator-related variability. Vaginal cuff in patients operated for benign reasonswas closed using a laparoscopic intracorporeal technique using 1/0 vycril or vaginally using 1/0 vycril.

Operation time, vaginal complications, and postoperative outcomes were compared between the two groups. The primary outcome of the study was the difference in baginal length measured preoperatively and at 3 months postoperatively.

Seconder outcomes included changes in sexual function as assessed by ASEX scores, operation time, and postoperative complications.

Operation time, vaginal complications, vaginal length, and postoperative sexual functions were compared between these two groups.

Patients who were operated on at an external center, patients who were operated by other surgeons, patients who developed intraoperative complications, patients who delayed their follow-up and treatment, patients who did not want to participate in the study, patients who were operated on for malignant reasons, patients with presence of a large adnexal mass (>10 cm in ultrasonography, >10 cm myoma on frozen section), patients who were operated on with indications, patients who were not sexually active, patients without a partner, and illiterate patients were not included in the study. Additionally, patients who could not tolerate the high Trendelenburg position, who were not suitable for laparoscopic surgery (patients with chronic obstructive pulmonary disease, restrictive lung disease), and who underwent laparotomy were excluded from the study. A total of 70 patients participated in the study during the planned 2-year period. However, 3 patients in the 1st group and 4 patients in the 2nd group were excluded from the study because they did not meet the study criteria.

CONSORT flow diagram summary: enrollment: 70 patients assessed for eligibility.

- Excluded: 7 (did not meet criteria or withdrew)

- Randomized: 63 (laparoscopic group: 32, vaginal group: 31)

- Follow-up: No loss to follow-up

- Analysis: 63 included (32+31)

A total of 63 patients were included in the study, 32 in the first group and 31 in the second group. A power analysis was performed based on previously published data showing a minimum expected mean difference of 0.25 cm in vaginal length and 1.5 points in ASEX scores between groups. To achieve 80% power at a 5% significance level (α=0.05), a minimum of 28 participants per group was required. We enrolled 63 patients in total to account for potential dropouts and maintain statistical power.

Patients were randomly assigned to the laparoscopic or vaginal cuff closure group using a computer-generated simple randomization sequence. Allocation was concealed in sequentially numbered, opaque, sealed envelopes that were opened in the operating room after anesthesia induction. This ensured minimization of selection bias.

Sexual function was assessed using the ASEX preoperatively and at 3 months postoperatively. Although several scales are available for evaluating female sexual function, ASEX was chosen for its brevity, ease of use, validation in Turkish populations, and its ability to quantify changes across domains such as sexual drive, arousal, lubrication, orgasm, and satisfaction. Sexual function was assessed using the ASEX, which has demonstrated reliability and validity in Turkish hemodialysis patients (5).

Vaginal length was assessed both preoperatively and at 3 months postoperatively. The measurement was performed with a graduated metal ruler (Hegar dilator with scale), introduced from the hymenal ring up to the vaginal cuff apex. Patients were placed in the lithotomy position without anesthesia during the procedure. All measurements were carried out by the same experienced gynecologist, who was blinded to the patient’s cuff closure technique to reduce bias. Although POP-Q parameters were recorded, the total vaginal length (TVL) measurement was used as the reference standard. To improve reproducibility, each measurement was performed twice, and the mean value was recorded. Trial registration: this study was registered at ClinicalTrials.gov (registration number: NCT07228351).

Statistical Analysis

Statistical analyses were performed using IBM SPSS statistics (version 25.0, IBM Corp., Armonk, NY, USA).While evaluating the study data, descriptive statistical methods were evaluated as mean, standard deviation and frequency. Student’s t test was used to compare normally distributed parameters between two groups, and Mann-Whitney U test was used to compare non-normally distributed parameters between two groups. Pearson correlation test was used to examine the relationships between parameters. Chi-square test was used tocompare qualitative data. The results were evaluated within the 95% confidence interval and the significance level was p<0.05.

Results

Our study was conducted with a total of 63 patients, 32 of whom underwent laparoscopic suturation and 31 of whom underwent vaginal suturation. Demographic data of both groups are shown in Table 1.

As seen in Table 1, the average age of the patients was 46.59±2.80 (years) in the patient group with laparoscopic suturation and 44.74±3.89 (years) in the patient group with vaginal suturation. When thegroups were examined, it was determined that the average ages in both groups ranged between 35 and 51 years, and the average ages were close to each other.

As seen in Table 1, the average height of the patients in the patient group with laparoscopic suturation was 161.78±4.79 cm, and the average height of the patients in the patient group with vaginal suturation was 160.74±5.50 cm. When the average weight of the patients in both groups was compared, it wasdetermined that the average weight in the patient group with laparoscopic suturation was 72.09±13.23 kg, and in the patient group with vaginal suturation it was 77.48±12.11 kg. While the highest weight was 102 kg in the patient group with vaginal suturation, the lowest weight was 50 kg in the laparoscopic suturation group.As seen in Table 2 when the operation times between the groups were compared, the average of the laparoscopic suturation group was 81.36±12.5 minutes, and the average of the vaginal suturation group was 88.46 min (minimum)±13.7 min.

As seen in Table 3; in the patient group that underwent laparoscopic suturation, the average pre-operative (pre-op) vaginal length was 8.63±0.97 cm, while the average post-operative vaginal length was 8.00±0.89 cm. The average difference in vaginal length was 0.67±0.22 cm.

In the patient group who underwent vaginal suturation, the average pre-op vaginal length was 8.60±0.90 cm, while the average post-operative vaginal length was 7.67±0.75 cm. The average difference in vaginal length was 0.92±0.30 cm. When the vaginal lengths of the two groups were compared, it was determined that the vaginal length was shortened more in the patient group who underwent vaginal suturation. A statistically significant difference was detected between the two groups (Table 3).

As seen in Table 4; when the complications were compared between the two groups, no vaginal vault hematoma was detected in the patient group with laparoscopic suturation, while vaginal vault hematoma was detected in 1 patient in the patient group with vaginal suturation. When comparedin terms of vaginal vault infection; while infection was detected in 2 patients in the laparoscopic suture group, infection was detected in 4 patients in the vaginal suture group. When compared in termsof vaginal vault dehiscence, one patient in each group was followed up with vaginal vault dehiscence. When evaluated in terms of complications; while vaginal vault hematoma and vaginal vault infection were more common in the patient groups that underwent vaginal suturation, no significant difference was detected between the two groups in terms of dehiscence.

As seen in Table 5; pre-op score in the patient group with laparoscopic suturation was 17.53±3.68, post-op score was found 18.53±3.56. The average ASEX score in the surveys conducted  in the pre-operative and post-operative periods in patients who underwent laparoscopic suturation was 1.38±1.5. In this group, the lowest score in pre-op patients was 10, while the highest score was 24. The lowest score of post-operative patients were 11 and the highest score was 25. The lowest ASEX score difference measured in pre-op and post-op patients was 0, while the highest was 6. There was no statistically significant difference between the groups in terms of the difference between pre-op and post-op measurements. This showed that the suturing technique in laparoscopic hysterectomy had no effect on the ASEX.

In the patient group who underwent vaginal suturation, the pre-op score was 16.52±4.29 and the post-op score was 17.16±4.98. The average ASEX score in the surveys conducted in the pre-op and post-operative periods in patients who underwent vaginal suturation was 1.1±1.1. In this group, the lowest score in pre-op patients was 8, while the highest score was 26. The lowest score of post-op patients was 8 and the highest score was 29. The lowest ASEX score difference measured in pre-op and post-op patients was 0, while the highest was 4 (Table 5).

As seen in Table 6, there was no significant correlation between the vaginal length and age (r=-0.185, p=0.146), height (r=- 0.04, p=0.975), weight (r=0.008, p=0.949), body mass index (demographic factors such as r=0.003, p=0.979), smoking history (r=0.038, p=0.768), comorbidity history (r=0.124, p=0.335), and previous operation history (r=-0.043, p=0.736).

Discussion

Although the specific advantages and disadvantages of laparoscopic hysterectomy have been gradually defined today, it is still not widely applied due to insufficient technical equipment and the lack of well-trained laparoscopically trained personnel.

We know that after hysterectomy, vaginal length shortens due to the removal of the uterus, andas a result, conditions such as dyspareunia and sexual dysfunction may occur. When the literature was examined, it was seen that few studies evaluated vaginal length after laparoscopic hysterectomy. Most of these studies evaluated vaginal lengths in different hysterectomy surgeries (vaginal hysterectomy, laparoscopic hysterectomy, abdominal hysterectomy) rather than different cuff closure methods. In some studies in the literature, vaginal cuff closure techniques were compared. In these studies, postoperative complications and operation times of both methods were compared. In a study, preoperative and postoperative vaginal length and sexual function scales were compared (6). In this study, the vaginal length in patients who underwent laparoscopic suturation was found to be longer than the vaginal length in patients who underwent vaginal suturation. In our study, the average pre- operative vaginal length in the patient group who underwent laparoscopic suturation was 8.63±0.97 cm, while the average post-operative vaginal length was 8.00±0.89 cm. The average difference in vaginal length was 0.67±0.22 cm. In the patient group who underwent vaginal suturation, the average pre-op vaginal length was 8.60±0.90 cm, while the average post-operative vaginal length was 7.67±0.75 cm. The average difference in vaginal length was 0.92±0.30cm. When the vaginal lengths of the two groups were compared, it was determined that the vaginal length was shortened more in the patient group who underwent vaginal suturation. Our data, consistent with the literature, revealed that postoperative vaginal length was shortened regardless of the cuff closure method.

When choosing the patients we included in the study, we made sure that they were similar groups. There was no significant difference in terms of demographic characteristics and surgery indications of the patients in both groups included in the study. This showed that the patients in the groups had a homogeneous structure. In addition, the fact that no significant difference was detected between the groups in terms of previous abdominal and pelvic surgical operations eliminated any possible differences between the groups.

When we looked at the operation times in our study, we noticed that the total operation time was shorter in the patient group who underwent laparoscopic suturation. In patients with laparoscopic suturation, although cuff suturing takes longer; we thought that the shortness of the total operation time was caused by the time loss during the examination of the abdomen with a camera after vaginal cuff suturing. We observed that there were time-consuming steps such as ensuring sterilization in accordance with the abdomen again after vaginal suturing, starting intra-abdominal gas inflation again, setting the appropriate pressure value, and rearranging the camera and other technical elements. Again, since we started working after gaining a certain amount of experience on this subject before laparoscopic suturation, we believed that the operation time of patients who underwent laparoscopic suturation was shorter.

In our study, postoperative total ASEX scores were higher in both groups compared to preoperative ASEX scores. (17.5-18.5/16.5-17.1). When all patient groups were examined, it was seen that the ASEX score was high. In our country, 53.1% of women aged 31-45 and 67.9% of women aged 46-55 have sexual dysfunction (7). However, the number of patients admitting for treatment is less. On sexual function; there are influencing factors that cannot be changed, such as the patient’s comorbid disease, menopause, and socioeconomic level. The postoperative ASEX form was filled out alone in a private room by the patients in our study, after their vaginal length was measured, when they came for their 3rd month follow-up. The answers here may be considered more realistic. Average ASEX score at the 3rd postoperative month in the patient group who underwent laparoscopic suturation was 18.5, and it was 17.1 in the patient group with vaginal suturing. However, the statistical difference was not significant (p>0.05).

One negative aspect of vaginal cuff closure is the increased risk of infection due to vaginal contamination. In our study, vaginal cuff infection was detected in 6.3% of the patient group who underwent laparoscopic suturation, while vaginal cuff infection was detected in 12.9% of the patients who underwent vaginal suturation. However, similar postoperative infection rates are reported in the literature in endoscopic and vaginal cuff closures (8). Infectious factor is an important risk factor for vaginal cuff detachment. When compared in terms of vaginal vault hematoma, no hematoma was detected in any patient in the patient group with laparoscopic suturation, while vaginal vault hematoma was detected in one patient in the patient group with vaginal suturation.

Study Limitations

This study has several limitations:

1.      Short follow-up duration: The postoperative evaluation was limited to 3 months. As sexual function may continue to evolve beyond this period, longer follow-up is warranted.

2.      Sample size: While powered to detect moderate differences, the relatively small cohort size limited the generalizability of findings.

3.      Randomization method: Although computer-based randomization was used, the single-center design and inclusion of only one surgeon might limit external validity.

4.      Selection bias: Despite randomization, baseline psychological and relationship factors influencing sexual function could not be fully controlled.

5.      Measurement bias: Self-reported ASEX scores might be affected by sociocultural factors or underreporting due to embarrassment or stigma.

6.      Choice of assessment tool: While ASEX is validated and practical, more detailed instruments such as the Female Sexual Function Index could offer broader insights into sexual domains. The use of ASEX was chosen for feasibility, but this might be seen as a limitation.

Conclusion

The purpose of our study was to investigate whether vaginal cuff closure techniques commonly used in total laparoscopic hysterectomy had an effect on vaginal length and sexual life, and to determine their superiority over each other, if any. For this purpose, we sutured the vaginal cuff using two different techniques: laparoscopic and vaginal. We found that laparoscopic vaginal cuff suturing shortened the vaginal length less. In terms of sexual life, we found that the vaginal cuff closure technique had no effect on postoperative results.

In terms of complications, although complications were less common in the patient group who underwent laparoscopic suturing in our study, the number of complications was quite low in both patient groups. We think that our findings should be supported by studies with a larger number of cases.

When we compare the two groups in terms of operation times; we found that the operation time was shorter in patients who underwent laparoscopic suturing. We believe that prospective, randomized, larger case series studies are needed to support our findings.