Hysterectomy, the surgical removal of the uterus, with or without the cervix and adnexa, is one of the most frequently performed gynecological procedures worldwide [1] . Common indications include uterine fibroids, abnormal uterine bleeding, endometriosis, uterine prolapse, and gynecological malignancies. The procedure can be classified into total (removal of uterus and cervix), subtotal (removal of the uterine body, leaving the cervix), and radical (removal of uterus, cervix, surrounding tissues, and lymph nodes) [2] . Surgical approaches include abdominal, vaginal, laparoscopic, and laparoscopy-assisted vaginal hysterectomy (LAVH) [3] .

Vaginal hysterectomy has a long history, predating the abdominal approach, and was traditionally favored for conditions like uterine prolapse [4] . Compared to abdominal hysterectomy, the vaginal route offers several advantages, including smaller incisions, reduced postoperative pain, shorter hospital stays, and faster recovery, making it a preferred option when feasible [2] [3] . Despite these benefits, its adoption remains inconsistent, particularly in low- and middle-income countries (LMICs), where abdominal hysterectomy continues to dominate [5] .

In Sub-Saharan Africa, including Cameroon, hysterectomy trends reflect broader healthcare challenges. A study in Nigeria found that abdominal hysterectomy accounted for 82% of cases, with vaginal hysterectomy performed in only 12%, primarily due to surgeon preferences, lack of training, the prevalence of large polymyomatous uteri or other pelvic conditions that may make vaginal access difficult [2] [5] .

In Cameroon, despite the availability of all three surgical approaches (abdominal, vaginal, and laparoscopic) [6] , abdominal hysterectomy remains the most commonly performed procedure, even at tertiary care facilities like the Douala General Hospital [2] [5] [7] . This predominance may not always align with best practice guidelines, particularly when considering the potential advantages of the vaginal route.

This study aimed to compare abdominal and vaginal hysterectomy in terms of perioperative and postoperative morbidity, cost, and recovery time at the Douala General Hospital. Understanding the relative benefits and drawbacks of each approach in our specific context is crucial for optimizing patient care. By comparing these two surgical routes, we hope to provide evidence to inform clinical decision-making, promote the appropriate use of vaginal hysterectomy when indicated, and ultimately improve the quality of gynecological surgical care at our institution and potentially other similar settings.

A total of 270 hysterectomies were performed during the study period, but only 215 patient files were enrolled for this study; 21 files could not be traced, and 34 had missing data. The average age of the patients was (49.65 ± 8.63) years, with an average parity of 3.69 ± 1.31. The majority of patients (66.5%) were married, and 41.4% were housewives ( Table 1 ).

In our study, 88.8% of hysterectomies were performed via the abdominal route, while 11.2% were vaginal. This distribution mirrors previous findings from the same institution [7] and aligns with trends observed in other West African studies [8] [9] . However, some studies report a higher frequency of vaginal hysterectomy.

Factors contributing to the low rate of vaginal hysterectomy at the DGH include the high prevalence of large, polymyomatous uteri, pelvic adhesions, and a limited number of surgeons skilled in the vaginal approach [2] . Practices in Cameroon, similar to many resource-constrained countries, have not fully embraced the recommendations of the International Society of Gynecologic Endoscopy (ISGE) or the trends seen in high-income countries, where vaginal hysterectomy is the preferred method for treating benign uterine conditions [4] [10] .

The mean operative time in our study was 184 minutes for abdominal hysterectomy and 136 minutes for vaginal hysterectomy. In contrast, European countries and the USA, where these techniques have been practiced for several decades with high-quality equipment, report significantly shorter durations, averaging 45 minutes for the abdominal approach and 32 minutes for the vaginal approach [11] . Studies from low- and middle-income countries (LMICs) show varying operative times, such as 58.45 minutes for abdominal and 87.55 minutes for vaginal procedures, as reported by Divya N. Alamelu et al. in Nigeria [12] and 29.9 minutes for vaginal hysterectomy in South Africa [13] . Several factors contribute to the disparities in operative durations across regions, including differences in surgical experience, mental state of the surgeon, case complexity, patient preferences, and procedure costs [2] . In Cameroon, the frequent presentation of patients with large, multiple uterine myomas and the limited number of specialists proficient in vaginal surgery contribute to longer operative times.

Regarding cost, our study found that vaginal hysterectomy was less expensive than abdominal hysterectomy. Vaginal hysterectomy is consistently reported as the least costly method compared to abdominal, laparoscopic, or other types of hysterectomy in both high- and low-income countries. The cost-effectiveness of vaginal hysterectomy can be attributed to shorter hospital stays, fewer surgical materials used, and a reduced complication rate. Similar findings have been reported by authors studying the cost-effectiveness of hysterectomy for benign conditions in Africa [2] and high-income countries [14] - [16] .

In terms of hospital stay, our study found an average length of 6 days for abdominal hysterectomy and 3 days for vaginal hysterectomy, consistent with the variation reported in the literature, which ranges from 5 to 9 days for abdominal hysterectomy and 1 to 5 days for vaginal hysterectomy in LMICs [17] - [19] . Several factors influence hospital stay post-hysterectomy, including the surgical route, patient-related factors (such as age and comorbidities), surgeon skill, aseptic techniques, and complications. In our setting, surgeons with moderate experience tend to extend hospital stays for patient safety. Other contributing factors include variations in postoperative care protocols and patient-specific conditions.

Uterine fibroids were the leading indication for abdominal hysterectomy (55.5%), while cervical dysplasia was the most common reason for vaginal hysterectomy (41.4%). In our setting, as in other LMICs, vaginal hysterectomy for a non-prolapsed uterus is restricted by certain criteria, including uterine size (less than 12 weeks), proof of benign disease, number of uterine fibroids, and history of previous laparotomy [12] [16] . However, other authors suggest that techniques such as myomectomy, bisection, and morcellation can overcome difficulties related to the size and number of fibroids, allowing vaginal hysterectomy to be performed regardless of uterine size [12] [13] [17] .

Intraoperative and postoperative complications were more frequently observed in the abdominal hysterectomy group, a trend commonly reported worldwide. These complications include intraoperative bleeding, organ injury, and postoperative fever [18] - [20] . This can be attributed to the larger surgical field and the increased potential for blood loss and tissue trauma associated with the abdominal approach. Notably, no deaths were recorded in either group during the study, which is consistent with findings in other LMICs.

Regarding the impact on quality of life, most patients resumed sexual activity within one month after surgery, showing no change in sexual arousal compared to their preoperative state. There was no significant difference between vaginal and abdominal hysterectomy in terms of time to return to sexual activity (p = 0.156). While the effect of hysterectomy on sexual function remains controversial, with some studies reporting no significant change, others note improvements or declines in sexual activity [21] - [24] . Factors such as sexual arousal, dyspareunia, vaginal dryness, and overall sexual activity may be influenced to varying degrees, with some studies reporting marked improvements in sexual activity [25] . In our study, postoperative dyspareunia rates were higher in the abdominal hysterectomy group (35.1%) compared to the vaginal group (20.8%), but this difference was not statistically significant (p = 0.322). These rates are higher than the 15% reported by Graesslin et al. [26] , but lower than the 90% rate reported by other authors who did not differentiate between surgical approaches. About 20% of patients reported cessation of intercourse, citing reasons such as fear (14%), marital issues (4.65%), and misinformation (1%), with no significant differences between groups (p = 0.156). Additionally, a reduction in the frequency of sexual intercourse was reported by 35.6% of abdominal hysterectomy patients and 25% of vaginal hysterectomy patients (p = 0.303), which is lower than the 44% reported by Barrat et al. [27] and similar to findings by Graesslin et al. where 15% reported reduced sexual activity against 15% who reported increased activity [26] .

While the retrospective design and limitations related to matching demographic characteristics and surgery indications may weaken the conclusions, this study provides valuable insight into the comparative outcomes of abdominal and vaginal hysterectomy. It offers a grounded foundation for future research that could incorporate more homogeneous patient groups, multi-center data, and longer follow-up periods to better evaluate the long-term effects of different hysterectomy techniques.

Abdominal hysterectomy remains the predominant approach at the DGH. However, this study underscores the advantages of vaginal hysterectomy, including shorter operative times, lower costs, and faster recovery. While early postoperative morbidity was slightly higher in the abdominal group, no significant differences were observed in overall complication rates. Although there were no significant differences in sexual function or self-perception between the two groups, trends suggest a potential negative impact, particularly after abdominal hysterectomy. These findings highlight the need to promote and expand the use of vaginal hysterectomy where clinically appropriate. Further research with larger sample sizes is needed to better understand the long-term effects of hysterectomy on quality of life and sexual function.

RT, TNN, FMN, and NCT conceptualized and designed the study. ANS, FKM, and CJNN were responsible for recruiting participants at the study sites. AGSW and HN also contributed to participant recruitment and provided feedback on the manuscript. The manuscript was written by TNN, RT, TOE, and FMN. HE, GHE, and NCT critically revised and reviewed the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.