Systematic review: Vaginal vault smears after hysterectomy for reasons other than malignancy: a systematic review of the literature

Abstract

Background Vaginal vault smears are used to detect persisting neoplasia of the lower genital tract after hysterectomy. Recent data suggest both widespread use and uncertain evidence of their effectiveness.Objectives To identify and synthesise evidence on the use and effectiveness of vaginal vault smears and to assess the quality. Selection criteria Primary research, women who had a hysterectomy and were followed up by vault cytology.Data collection and analysis Systematic search (eight electronic databases), supplemented by contact with experts and review of bibliographies. Two independent reviewers determined eligibility/ validity and extracted data concerning test performance characteristics. Quality was assessed according to the established criteria.Results Of 441 unique references, only 19 were suitable. Quality of studies varied considerably and few were of 'high' methodological quality. Studies were geographically diverse, and were published over more than 40 years in 16 journals. From the higher scoring papers, there were 11 659 hysterectomies [6546, benign; 76, cervical intraepithelial neoplasia (CIN) I/CIN II; 5037, CIN III]. Proportions of abnormal vault smears and abnormal biopsies during follow up increased with worsening histology at hysterectomy (P < 0.0001 and P = 0.0001). There was only one report of vaginal cancer subsequent to hysterectomy for CIN and insufficient data to allow for reliable meta-analysis.Conclusions Vault smears cause anxiety, consume resources and their value is largely unproven. Inconsistency of study design and limited methodological quality means that the value of vault smears could not be established. High-quality research is required to ensure that the guidelines are evidence based.

The impact of human papillomavirus vaccination on cervical cancer prevention efforts

“…The risk of cancer in young women is quite low, and assessment of changes in cervical cancer rates where comprehensive screening has been initiated suggests that screening has little impact on rare early-onset cancers, especially those presenting before age 25 (10). Screening after hysterectomy for benign indications also is not cost-effective, though still commonly done (11, 12). Overscreening can result in patient harms, including missed work, travel and child care costs, anxiety, stigmatization, and obstetric and surgical complications from treatment of lesions that would not have progressed to cancer (13, 14).…”

Risk of vaginal cancer among hysterectomised women with cervical intraepithelial neoplasia: a population‐based national cohort study

“…It has been clearly shown that women with CIN3, despite treatment, are at increasing risk of cervical or vaginal cancer at advanced ages, but the specific cancer risk for women who undergo total hysterectomy was not known. There are few studies addressing this issue and they show conflicting results …”

Laparoscopic Subtotal Hysterectomy: Evidence and Techniques

“…The reported risk of cervical cancer after subtotal hysterectomy is low, 0.1% to 1.9% [88]. The reported risk of cancer at the vaginal vault is 0.03% in women who undergo total hysterectomy to treat cervical intraepithelial neoplasia 3; there is no reported case of cancer occurring at the vaginal vault after total hysterectomy performed to treat benign indications other than cervical intraepithelial neoplasia [89]. An ACOG guideline reports that women with known or suspected gynecologic cancer, current or recent cervical dysplasia, or endometrial hyperplasia are not candidates for subtotal hysterectomy [90]; however, fear of future cervical stump carcinoma should not discourage those with a history of normal cervical surveillance from undergoing subtotal hysterectomy.…”