Abdominal hysterectomy remains the preferred approach for large uteri or in case of narrow vaginal access. However, the traditional morcellation techniques allow safe and efficient extraction when choosing the vaginal route. Uterine volume reductive techniques do not increase perioperative morbidity thus complications do not seem to be linked to uterine size. There are numerous advantages of the vaginal route in comparison with laparotomy, such as aesthetic benefits, decreased postoperative pain, reduced hospital stay and recovery as well as decreased perioperative morbidity. Compared to laparoscopy, surgical outcomes and blood loss of the vaginal approach of a large uterus seem to be similar. Nevertheless, laparoscopic hysterectomy is associated with longer operative time and significant increase in hospital cost. Hence, a thorough knowledge and mastery of uterine morcellation techniques are essential when performing vaginal hysterectomy for large uteri or when the vagina is narrow. They must therefore continue to be taught, spread and regularly used in order to stretch the indications for vaginal hysterectomy in favour of an abdominal approach.