Vaginal cuff dehiscence and evisceration are rare but serious complications of pelvic surgery, specifically hysterectomy. The data on risks of vaginal cuff dehiscence are variable, and there is no consensus on how to manage this complication. In our review, we present a summary of the risk factors, with symptoms, precipitating events, and treatment options for patients with vaginal cuff dehiscence after pelvic surgery. In addition, we provide a review of the current literature on this important surgical outcome and suggestions for future research on the incidence and prevention of vaginal cuff dehiscence.
Hysterectomy is the most frequently performed major gynecologic surgical procedure. Between 2000 and 2004, 3.1 million hysterectomies were performed in the United States. Vaginal cuff dehiscence and vaginal evisceration, although rare, are serious postoperative complications after hysterectomy or other pelvic surgery. Because the data on the risks of vaginal cuff dehiscence are variable and there is no consensus on how to manage this complication, we performed a review of original research, case reports, and case series that have been published in the past 30 years on vaginal cuff dehiscence. In this review, we present a summary of the published evidence, risk factors, presenting symptoms, precipitating events, and treatment options for patients with vaginal cuff dehiscence after pelvic surgery.
Limited body of evidence
Although vaginal cuff dehiscence is a serious complication for the patient and the provider, its low incidence makes it difficult to study. In reviewing the literature, we identified only 44 pertinent publications on vaginal cuff dehiscence, 68% (30/44) of which were case reports that involved ≤2 patients. Overwhelmingly, the published information on vaginal cuff dehiscence consists of case reports, which are inherently problematic because of selection bias. Physicians tend to write up interesting or unusual cases for publication, and because the denominator is unknown, it is not possible to estimate rates. Of the remaining studies that we reviewed, 3 were case series (≥3 patients) ; 4 were “descriptive studies” (reviewing all hysterectomies that were performed at an institution over a certain time period and specifically detailing vaginal cuff dehiscence) ; 2 were retrospective cohort studies ; 1 was a randomized clinical trial, and 3 were expert opinion articles that contained some discussion of vaginal cuff dehiscence. A summary of the case reports, case series, and descriptive studies are presented in Table 1 .
| Study, with brief description | Incidence | Mean age, y | Type of pelvic surgery | Mean interval to dehiscence (range) | Proportion with evisceration (%) | Method of closure |
|---|---|---|---|---|---|---|
| Croak et al : description of all vaginal eviscerations at a single institution from 1970-2001 | 0.032% (denominator not given) | 63 | 42% TAH; 33% TVH; 25% other/trauma | 2.25 y (5 mo–4 y) | 50 | 8% abdominal; 58% vaginal; 25% vaginal/abdominal combination; 8% vaginal/laparoscopic combination |
| Iaco et al : description of all vaginal dehiscences after hysterectomy at a single institution between 1995-2001 | 0.27% (10/3593 patients) | 57.5 | 60% TAH; 30% TVH; 10% TLH | 1.6 y (2 mo–5.4 y) | 70 | 100% abdominal |
| Hur et al : description of all vaginal dehiscences at a single institution from 2000-2006 | 0.14% (10/7286 patients) | 39.9 | 10% TAH; 10% TVH; 80% TLH | 2.75 mo (1 mo–1 y 3 mo) | 60 | 90% vaginal; 10% vaginal/abdominal combination (to allow concomitant pelvic organ prolapse procedures) |
| Agdi et al : series of 16 cases of vaginal cuff dehiscence reported via American Association of Gynecologic Laparoscopists list-server and literature review | NA | 44 | 6% TAH; 94% TLH | 3 wk (3–6.5 wk) | NA | NA |
| Kho et al : description of all vaginal dehiscences after robotic hysterectomy at a single institution from 2004-2008 | 4.1% (21/510 patients) | 45 | Robotic hysterectomy, vaginectomy, or trachelectomy | 1.5 mo (2 wk–4.5 mo) | 29 | 90% vaginal; 5% vaginal/laparoscopic combination; 5% secondary intention |
| Nick et al : retrospective cohort study of TLH and robotic hysterectomy from 2000-2009 | 1.7% (7/417 patients) | 30 | All TLH and robotic | 4.3 mo (1.9–5.8 mo) | 43 | 43% vaginal; 57% secondary intention |
| Multiple studies: summary of 32 case reports and series (26 articles with 1 patient, 4 articles with 2 patients, 2 articles with 3 patients) | NA | 58.8 | 35% TAH; 45% TVH/LAVH; 15% TLH/robotic; 2% other | 3.93 y (3 d–30 y) | 95 | 52.5% abdominal; 32.5% vaginal; 5% laparoscopic; 10% vaginal/laparoscopic combination |
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