Background: It is uncertain whether the dramatic increase in the number of vaginal hysterectomies performed in the United States between 1988 and 1993 is the result of improved medical and economic outcomes associated with the vaginal approach or is caused by a proliferation of postgraduate courses in vaginal surgery. Many conditions assumed to contraindicate the vaginal approach have not withstood scientific scrutiny. Although better outcomes have been associated with the vaginal approach, unintentional operative cystotomy with the procedure is a concern, especially in patients who underwent previous cesarean section.Discussion: Office and hospital records of 3,447 patients undergoing vaginal hysterectomy were reviewed. The indications for surgery, age, parity, and uterine weight were analyzed and compared with patients who underwent previous cesarean section and those who did not. A total of 2,793 (80%) patients who did not undergo previous cesarean section underwent hysterectomy; 654 (20%) patients underwent previous cesarean section. The overall incidence of operative cystotomy was 21 of 3,447 (0.6%).Summary: The low incidence of the operative cystotomy complication in patients who did and did not undergo previous cesarean section merits consideration by gynecologic surgeons who perform vaginal hysterectomy.