This was a prospective, interventional longitudinal cohort study conducted in the Department of Obstetrics and Gynaecology at ESI, PGIMSR, Basaidarapur, New Delhi. From December 2018 to November 2019, all women undergoing vaginal hysterectomy for benign conditions (uterovaginal prolapse, adenomyosis, fibroids) were offered prophylactic salpingectomy. The preoperative diagnosis was made based on the findings on Ultrasonography as well as clinical examination. Permission was obtained from the Institutional Ethics Committee {DM(A)H-19/14/17IEC/2012-PGIMSR} before the start of the study. The study was conducted according to the ethical principles stated in the latest version of Helsinki Declaration, and the applicable guidelines for Good Clinical Practice (GCP).

Inclusion criteria: All women undergoing vaginal hysterectomy for benign conditions.

Exclusion criteria: History of removal of a fallopian tube or ovary, had known tubo-ovarian pathology, opted for oophorectomy at the time of hysterectomy and were not willing to participate in the study. Patients with severe endometriosis with cul-de-sac obliteration were also excluded.

A study conducted by Lin YS et al., had reported that 76% of patients had successfully undergone bilateral salpingectomy [10]. Considering a margin of 15%, a sample size of 35 patients was arrived for this study. The primary outcome of the study was to estimate the proportion of patients in whom bilateral prophylactic salphingectomy could be successfully completed vaginally whereas the secondary outcomes were additional length of time, EBL and factors associated with non completion of planned bilateral salpingectomy.

Baseline patient characteristics such as age, parity, Body Mass Index (BMI), relevant medical and surgical history along with the reason for vaginal hysterectomy were noted from the medical records of the patient prior to the surgery. Details pertaining to surgical procedure (vaginal hysterectomy with bilateral prophylactic salphingectomy), intraoperative findings, complications, salpingectomy start and end time, and EBL for salpingectomy were noted during the procedure. After assuring the haemostasis of hysterectomy pedicles, salpingectomy operative time started when the adnexal pedicle was first grasped to search for the fallopian tube on the first side. Salpingectomy operative time ended after achieving haemostasis of the bilateral fallopian tube pedicles. A standardised technique was employed involving a single or double clamp to clamp across the mesosalpinx and a single or double suture-ligation to secure the pedicle following excision of the fallopian tube. The salpingectomy surgery included the removal of the fallopian tube along with fimbria. Patients were followed-up for six weeks for any complications.

All the relevant data was entered in MS-Excel and statistical analysis was performed using SPSS version 17.0. Continuous variables were described with mean whereas categorical variables were described with frequencies and percentages. ANOVA was used for comparison of normally distributed continuous variables between the groups. A p-value of <0.05 was taken as significant.

Thirty-five patients agreed and were enrolled to be a part of present study. Mean age of study participants was 56.95±5.62 years. Mean age at marriage of participants was 18.14±1.55 years. Mean BMI of the patients was 22.77±4.05 kg/m². Mean parity was 4.9±1.44. The demographic characteristics of the study population are depicted in [Table/Fig-1]. Significant medical or surgical history was noted in 21 (60%) patient [Table/Fig-2]. The indications for vaginal hysterectomy included uterovaginal prolapse in 21 (60%) patients and adenomyosis and fibroids in 10 (30%) and 4 (10%) patients respectively. Vaginal salpingectomy was successful in 31 (88.5%) patients. Of the four patient in whom vaginal salpingectomy could not be done, 2 (5.7%) had pelvic adhesions whereas in the remaining two cases tubes were pulled up due to atrophic ovaries.

Mean operating time for bilateral vaginal salpingectomy was 14.05±2.75 minutes. Mean EBL for bilateral salpingectomy was 19.86±6.88 mL [Table/Fig-3]. Intraoperative bradycardia and haematoma formation was observed in two patients each that was managed whereas bleeding was observed in one patient but none of these were related to bilateral salpingectomy. Blood transfusion was required in two patients whereas none of the patients had bladder or bowel injuries [Table/Fig-4,5]. At a follow-up of six weeks, four patients had some vaginal infection and rest all were normal [Table/Fig-6].

With the limitation of minimal increases in operative time and blood loss, vaginal salpingectomy is feasible in majority of the women undergoing vaginal hysterectomy. As compared to the hysterectomy alone or tubal ligation, the procedure does not increase the risk of other postoperative complications such as blood transfusions, readmissions, infections or fever [3]. This provides an opportunity to reduce the rate of ovarian cancer in the future. The vaginal approach is preferred, because it has the lowest complication rates. The ACOG recommend vaginal hysterectomy over laparoscopic and abdominal approaches for benign disease because of lower complication rates and shorter operative times [11]. Although the rates of prophylactic salpingectomy are increasing as per ACOG recommendations, the rates of salpingectomy at the time of vaginal hysterectomy still remain low [12,8]. In one study, only 16.5% of women undergoing vaginal hysterectomy had prophylactic salpingectomy, as compared to 55.8% of hysterectomies performed by other routes [8]. To the best of the knowledge, no previous studies on this topic have been reported for Indian population.

The successful salpingectomy rate of 88.5% achieved in present study is consistent with the findings of a study published in Canada [13]. The study showed ageing and pelvic adhesions as the risk factors for unsuccessful removal although the major limitation of this study was its retrospective design [13]. The findings of present study are in compliance with these observations. Antosh DD et al., reported that prior adnexal surgery and fibroids as an indication for surgery were associated with unsuccessful completion of planned vaginal salpingectomy [2]. Prior adnexal surgery may predispose to tubal adhesions [2].

The present study had longer mean operating time and higher mean blood loss for bilateral vaginal salpingectomy in comparison to study done by Antosh DD et al., [2]. In present study, mean operating time for bilateral vaginal salpingectomy was 14.05±2.75 minutes and mean EBL for bilateral salpingectomy was 19.86±6.88 mL. Similarly, the study by Antosh DD et al., showed a minimal increase of 11 minute in the operative time along with a 6 mL increase in the EBL with salpingectomy [2]. In present study, there were no complication related to bilateral salpingectomy. The over rate of 14% complication during vaginal hysterectomy was comparable to Canadian study which reported 15% of complication during vaginal hysterectomy [13]. A recent study by Hanley GE et al., reported no increase in complications with the addition of salpingectomy at the time of hysterectomy [4]. While a study by Cadish LA et al., had shown more major complications (7.95% vs. 7.68%) with planned opportunistic salpingectomy as compared to the hysterectomy alone [9].

Strengths of this study include its prospective design, although small sample size appears to be limiting factor. However, planned bilateral salpingectomy at the time of vaginal hysterectomy is feasible and likely to be successful with minimal additional time, blood loss, and risk. Vaginal surgeons should feel confident and practice it routinely.

The major limitation of this study was its small sample size. Further studies with a larger sample size to identify the risk factors for successful removal seems warranted.

Routine salpingectomy should be offered to women undergoing vaginal hysterectomy for benign conditions to prevent risk of ovarian carcinoma in future.