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

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. Search strategy ‘vault smear’ OR ‘vaginal vault smear’ OR ‘cervical vault smear’ OR (‘Hysterectomy’) AND (‘Follow up’ OR ‘Smear’). 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.