Pre-operative ultrasonographic evaluation of nongravid, enlarged uteri — correlation with bimanual examination

doi:10.1016/S0301-2115(98)00118-3

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 80, Issue 2, 1 October 1998, Pages 205-207

https://doi.org/10.1016/S0301-2115(98)00118-3 Get rights and content

Abstract

Objective: To correlate the size of the nongravid uterus measured by ultrasound and bimanual examination before hysterectomy, with the actual size of the specimens. Patients and Methods: Uterine size of 49 consecutive patients, who underwent elective hysterectomy, was assessed by bimanual pelvic examination, preoperative ultrasonographic evaluation and actual postoperative size. Results: All preoperative ultrasonographic uterine dimensions significantly correlated with the corresponding actual dimensions of the uterine specimens. Furthermore, ultrasonographic uterine length had the best correlation with uterine size estimation by bimanual examination. A formula was established in an attempt to calculate clinical uterine size by gestational week, using preoperative ultrasonographic dimensions. Conclusions: By using the aforementioned formula, ultrasonographic uterine dimensions can be extrapolated to uterine size in terms of gestational week, and therefore, be applicable to traditional clinical practice.

Introduction

It is common gynecological practice to estimate the size of nongravid, enlarged uteri by comparison with pregnant uteri of comparable size. During the last decade, ultrasonographic evaluation of uterine dimensions was introduced by different clinicians, into routine gynecological practice, as an objective way of communicating uterine sizes. However, this ultrasonographic evaluation does not express the size using a standard method, and therefore makes it difficult for the clinician to correlate the findings with this clinical estimation. The purpose of this study was: (1) to determine the validity of ultrasound for accurate prediction of uterine size in nongravid patients through correlation with hysterectomy specimens; and (2) to assess the correlation between preoperative ultrasonographic and bimanual examinations.

Section snippets

Patients and methods

During a 7-month period, 49 consecutive women (mean age 49.6±7) who were admitted for hysterectomy at the Rabin Medical Center, Petah Tikva, were recruited to participate in the study. The inclusion criteria included patients who were scheduled to undergo elective hysterectomy because of the presence of any of the following indications: menorrhagia or metrorrhagia causing anemia, enlarged fibroid uterus of >12 weeks' gestation, and fast-growing fibroid uterus.

Upon admission for elective

Results

The preoperative ultrasonographic measurements of the three maximal uterine dimensions of length, depth and width were 11.04±2.45 cm, 8.61±2.27 cm and 7.30±1.88 cm, respectively. While comparing these measurements, together with the calculated uterine volume (401.24±308.29 cm³), to the actual corresponding postoperative uterine dimensions, the best correlation was achieved by comparing uterine length (r=0.8734, P<0.0001), while the correlation between the ultrasonographic and actual uterine

Discussion

The American College of Obstetricians and Gynecologists (ACOG) established some guidelines for the route of hysterectomy [1]by stating that the choice depends on patient anatomy, including uterine size and experience of the surgeon. The indications and contraindications for each surgical approach to hysterectomy has recently been further complicated by proponents of laparoscopy-assisted vaginal hysterectomy, which is believed to extend the vaginal hysterectomy option to many patients who had

Condensation

A formula was established in an attempt to calculate clinical uterine size in terms of gestational week, by using preoperative ultrasonographic dimensions.

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Cited by (14)

Preoperative Factors That Predict the Need to Morcellate in Total Laparoscopic Hysterectomy
2018, Journal of Minimally Invasive Gynecology
Citation Excerpt :
Our study found that preoperative uterine measurements that most accurately predict the need to morcellate at the time of TLH are bimanual exam, uterine cross-sectional area, and size of the largest leiomyoma. Prior studies on this subject have used uterine pathologic weight to determine cut-offs as to which specimens will require morcellation and then have relied on conversion equations to translate uterine weight to estimated preoperative uterine volume [23–26]. This is the first study to our knowledge to evaluate all uterine measurements that may be available preoperatively.
To determine which preoperative factors best predict the need for uterine morcellation at the time of total laparoscopic hysterectomy (TLH) and to identify cut-offs that can help guide clinical decision-making.
Retrospective cohort (Canadian Task Force classification II).
Tertiary care center.
Women (n = 420) who underwent TLH between July 2012 and June 2015: 223 cases without and 197 cases with morcellation.
Laparoscopic hysterectomies with either laparoscopic power, vaginal, or open morcellation via mini-laparotomy were analyzed.
Preoperative factors assessed included uterine volume, cross-sectional area, length, size of largest leiomyoma, and bimanual exam. Receiver operator curves (ROC) were used to establish cut-offs that maximized sensitivity and specificity for each factor. Bivariate and multivariate Poisson regression analyses were used to calculate relative risks associated with these objective cut-offs. ROC curves demonstrated maximized sensitivities and specificities with a cross-sectional area of 48.6 cm², largest leiomyoma dimension of 4.4 cm, bimanual exam of 11.5 weeks, and uterine volume of 262 mL. Multivariate Poisson regression analysis revealed that the strongest predictors of morcellation were cross-sectional area (adjusted relative risk, 2.94; 95% confidence interval, 1.20–7.19), largest leiomyoma diameter (adjusted relative risk, 2.06; 95% confidence interval, 1.24–3.41), and bimanual exam (adjusted relative risk, 1.88; 95% confidence interval, 1.05–3.37).
Uterine cross-sectional area, largest leiomyoma dimension, and uterine size on bimanual exam can all be used to predict the need to morcellate at the time of TLH.
Hysterectomy for benign gynaecological disease: Surgical approach, vaginal suture method and morcellation: Guidelines
2015, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Éditer des recommandations pour la pratique clinique sur la voie d’abord, la technique de fermeture vaginale, l’expérience chirurgicale et le morcellement dans le cadre de la prévention des complications de l’hystérectomie pour pathologie bénigne par le Collège national des gynécologues et obstétriciens français (CNGOF).
Revue exhaustive de la littérature anglo-saxonne et française sur les complications de l’hystérectomie, pathologie maligne exclue.
En cas d’hystérectomie pour pathologie bénigne, il est recommandé de préférer l’hystérectomie cœlioscopique (HC) ou vaginale (HV) (grade B). Si l’utérus est gros, l’HV ou l’HC sont recommandées (grade C). L’HV pour pathologie bénigne n’est pas contre-indiquée en cas de nulliparité (Grade C). L’HV pour pathologie bénigne n’est pas contre-indiquée en cas d’antécédent de césarienne (grade C). Chez une patiente obèse, l’HV ou l’HC sont recommandées (grade C). Il est recommandé de réaliser au moins 30 hystérectomies au cours de son apprentissage (grade C). Il est recommandé qu’une hystérectomie soit réalisée par un chirurgien pratiquant au moins 10 hystérectomies par an (grade C). Aucune méthode spécifique de fermeture vaginale n’est recommandée (grade C). Il est recommandé d’évaluer le risque néoplasique avant hystérectomie (prélèvement histologique et/ou imagerie) en cas de morcellement prévisible (accord professionnel).
To provide clinical practice guidelines from the French college of obstetrics and gynaecology (CNGOF), based on the best evidence available, concerning the surgical approach, the vaginal suture method, the surgeon's experience and morcellation to avoid complications with hysterectomy for benign gynaecological disease.
English and French review of literature about complications with hysterectomy for benign gynaecological disease, excluding cancer.
For benign gynaecological disease, vaginal (VH) or laparoscopic (LH) hysterectomy are recommended (grade B). In case of big uterus, VH or LH are recommended (grade C). VH is not contraindicated in nulliparous (Grade C). VH is not contraindicated in case of previous caesarean (grade C). In obese women, VH and LH are recommended (grade C). It should be recommended to perform at least 30 hysterectomies during learning curve (grade C). Hysterectomy should be performed by surgeon doing at least 10 hysterectomies each year (grade C). No vaginal suture method is recommended (grade C). It is recommended to assess cancer risk before (histological sample and/or imagery) when morcellation is planned (expert opinion).
The estimated volume of the fibroid uterus: A comparison of ultrasound and bimanual examination versus volume at MRI or hysterectomy
2015, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
However, the study included only twelve patients and the differences were not significant [28]. Three studies showed that ultrasonographic dimensions significantly correlate with the true dimensions of the removed uteri as described in histopathology reports [16,17,21]. Moreover Flickinger et al. found greater errors in estimates of the uterine size when using bimanual examination than by ultrasonography, when compared with the actual uterine volume after hysterectomy [17].
The volume of a fibroid uterus before performing hysterectomy is typically estimated through bimanual examination and confirmed by ultrasonography. This study compares estimated volumes by bimanual examination and ultrasound examination with MRI and actual volumes obtained from histopathology, as gold standards.
We used data from a previous prospective randomized multi-center trial that compared hysterectomy and uterine artery embolization (UAE) for the treatment of symptomatic fibroids. All patients underwent bimanual vaginal examination and pelvic ultrasonography. Those women randomized to UAE received a pelvic MRI. For women randomized to hysterectomy, the exact uterine volume was based on histopathologic examination. We compared the calculated volumes based on ultrasound parameters and estimated volume based on bimanual examination with either the calculated volumes of the pelvic MRI parameters or the calculated volume based on the exact weight during histological examinations.
Our study demonstrated poor agreement between ultrasound and bimanual examination compared with exact volume during histopathologic examination and MRI-based volume. The agreement within the patient group with uterine volume >233 g and >747 g was fair to good. For those women with a uterine volume between 233 and 747 g, the agreement was poor when comparing bimanual estimates with volume obtained from MRI or histolopathologic examination. Within this volume group, the agreement on uterine volume between ultrasound and MRI or histopathologic examination was fair.
Our study shows that uterine volume as estimated by ultrasound and bimanual examination can be used for small or large uteri. For uteri with an intermediate volume, bimanual examination and ultrasound are less reliable.
Ultrasonographic assessment of weight of the myomatous uterus: A pilot study using a new combined geometrical formula
2008, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Ultrasonographic estimation with a geometric formula for a prolate ellipsoid is the most common method of calculating the size of the uterus. Some investigators have measured only the length of the uterine corpus for the formula, leaving the mass of the uterine cervix outside the estimation of total uterine volume [3,4,11,12]. Other investigators have measured the length of the uterus from its fundus to the external os of the cervix, the cervix being thought to lie in the ellipsoid [1–2,5–7].
To evaluate the accuracy of a formula combining the prolate ellipsoid (uterine corpus) and cylinder (uterine cervix) formulas in estimating the preoperative weight of the total uterus using a transvaginal ultrasound probe to obtain the uterine dimensions for the formulas.
Three dimensions of the uterine corpus (length, width and anteroposterior diameter) and cervical length and cervical anteroposterior diameter were preoperatively determined using a transvaginal ultrasound probe in 12 women with symptomatic leiomyomas scheduled to undergo hysterectomy. In two patients whose uteruses were the largest, part of the measurements had to be taken with a transabdominal ultrasound. Three investigators repeated all the rounds of measurements three times, producing in total 108 of findings (12 subjects × 3 investigators × 3 rounds of measurements).
The geometric formula of prolate ellipsoid was compared to a formula combining the ellipsoid and cylinder formulas for accuracy in predicting overall uterine size (corpus and cervix) through correlation with hysterectomy specimens. The weight of the uterus in grams was directly derived from the volume of the uterus.
All measurements of the uterine corpus and cervix could be obtained preoperatively with a transvaginal ultrasound probe except in two patients who had the largest uteruses. The plain, traditional formula for the prolate ellipsoid overestimated the weight of the uterus and differences between the estimated and the true weight were statistically significant. The difference was not significant when the formula combining the formulas of the prolate ellipsoid and cylinder was used.
The new formula combining the prolate ellipsoid and cylinder formulas is more accurate in predicting the true total weight of the uterus than the plain prolate ellipsoid formula. The transvaginal ultrasound probe proved useful in evaluating the dimensions of the uterine corpus and cervix.
What is the value of preoperative bimanual pelvic examination in women undergoing laparoscopic total hysterectomy?
2007, Journal of Minimally Invasive Gynecology
To estimate the value of preoperative bimanual examination of the pelvis in women undergoing total laparoscopic hysterectomy (TLH).
Prospective observational cohort study.
Private hospitals and centre.
One hundred fourteen consecutive women undergoing TLH.
All women who were scheduled to undergo TLH from May 2005 through June 2006 had a bimanual examination of the pelvis performed before surgery and the size of the uterus clinically estimated and recorded as gestational equivalents. The operating time, the estimated blood loss (EBL) during TLH, and the final weight of the uterus at histologic study were recorded. Spearman correlation coefficient analysis was used to determine whether there was a correlation between the estimated uterine size before surgery and actual uterine weight, operating time, and EBL.
Of the one hundred fourteen consecutive women eligible for the study, 75 had complete data and therefore were included in the final analysis. The median age was 46 years (range 34–71 years); 22.7% (17/75) had a clinically estimated normal uterus, 10.7% (8/75) had an 8–10/40 uterus, 12% (9/75) had a 10–12/40 uterus, 14.6% (11/75) had a 12–14/40 uterus, 20.0% (15/75) had a 14–16/40 uterus, 9.3% (7/75) had a 16–18/40 uterus, and 10.7% (8/75) had an 18–20/40 uterus. The median operating time was 110 minutes (range 59–240 minutes); the median EBL was 80 mL (range 20–1000 mL); and the median weight of the uterus was 181 g (range 52–1080 g). Histologic diagnoses included leiomyomata in 64.0% (48/75), adenomyosis in 44.0% (33/75), endometriosis in 22.7% (17/75), endocervical polyp in 4.0% (3/75), and normal uterus in 8.0% (6/75). The Spearman correlations between clinical size of the uterus and the weight of the uterus, the EBL, and the operating time were 0.81, 0.33, and 0.29, respectively; that is, the 2 variables tended to increase together. These correlations were all significant (p <.0001, .0044, and .0114, respectively).
This study showed significant correlation between clinical estimate of uterine size and histologic weight of the uterus, operating time, and EBL in women undergoing laparoscopic hysterectomy. These findings are of great value in preoperative counseling in relation to the risk of bleeding and the potential need for blood transfusion, and in operating room planning.
Abdominal or vaginal hysterectomy for enlarged uteri: A randomized clinical trial
2002, American Journal of Obstetrics and Gynecology
Citation Excerpt :
Through a computer-selected randomization, we assigned the patients to the study (vaginal hysterectomy) or control groups (abdominal hysterectomy). The ultrasonographic volume of their uteri7 ranged between 200 and 1300 mL. After hysterectomy, the uterine weight (grams) corresponded to the ultrasonographic volume.
Objective: The purpose of this study was to compare advantages, disadvantages, and outcomes in patients who undergo vaginal or abdominal hysterectomy for enlarged symptomatic uteri. Study Design: In a prospective, randomized study, 60 vaginal hysterectomies (study group) were compared with 59 abdominal hysterectomies (control group); all of the hysterectomies were performed for symptomatic uterine fibroids from January 1997 through December 2000. We excluded from the study the other common causes of hysterectomy such as prolapse, bleeding, adenomyosis, and endometrial or cervical carcinoma. In both groups, uterine weights ranged from 200 g to 1300 g. For enlarged uteri, vaginal hysterectomies were performed with the use of volume reduction techniques: Intramyometrial coring, corporal bisection, and morcellation. The evaluated parameters included patient age, weight, parity, uterine weight, operative time, blood loss, demand for analgesics, eventual surgical complications, length of admission, and hospital charges. The Mann-Whitney U test and χ² tests were applied for statistical analysis. Probability values of <.05 were considered statistically significant. Results: There were no major differences in patient age, weight, parity, and uterine weight between the two groups. Operative time was significantly lower for the vaginal route as compared with the abdominal route (86 minutes vs 102 minutes, P <.001). No intraoperative complications were noted both in the study and control groups or the control group. Surgical bleeding (expressed by hemoglobin loss) was not significantly different between the two groups. In the postoperative period, we found a higher incidence of fever (30.5% vs 16.6%, P <.05) and demand for analgesics (86% vs 66%, P <.05) in the abdominal group as compared with the vaginal group. Significant advantages of vaginal hysterectomy were a reduction in the hospital stay (3 days vs 4 days, P <.001) and cost. Conclusion: These results should lead to the choice of vaginal hysterectomy as a valid alternative to the abdominal hysterectomy, even for enlarged uteri. (Am J Obstet Gynecol 2002;187:1561-5.)

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