Surgical approach to hysterectomy for benign gynaecological disease

Background There are three approaches to hysterectomy for benign disease - abdominal hysterectomy (AH), vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions - laparoscopic assisted vaginal hysterectomy (LAVH) where a vaginal hysterectomy is assisted by laparoscopic procedures that do not include uterine artery ligation, laparoscopic hysterectomy (which we will abbreviate to LH(a)) where the laparoscopic procedures include uterine artery ligation, and total laparoscopic hysterectomy (TLH) where there is no vaginal component and the vaginal vault is sutured laparoscopically. Objectives To assess the most appropriate surgical approach to hysterectomy. Search strategy We searched the Cochrane Menstrual Disorders & Subfertility Group's Specialised Register of controlled trials (searched 23 March 2004), CENTRAL (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to Mar 2004), EMBASE (1985 to Mar 2004), Biological Abstracts (1968 to Mar 2004), the National Research Register and relevant citation lists. Selection criteria Only randomised trials comparing one surgical approach to hysterectomy with another were included. Data collection and analysis Twenty-seven trials that included 3643 participants were included. Independent selection of trials and data extraction were employed following Cochrane guidelines. Main results The benefits of VH versus AH were shorter duration of hospital stay (WMD 1.0 day, 95% CI 0.7 to 1.2 days), speedier return to normal activities (WMD 9.5 days, 95% CI 6.4 to 12.6 days), fewer unspecified infections or febrile episodes (OR 0.42, 95% CI 0.21 to 0.83). The benefits of LH versus AH were lower intraoperative bloodloss (WMD 45.3 mls, 95% CI 17.9 to 72.7 mls) and a smaller drop in haemoglobin level (WMD 0.55g/L, 95% CI 0.28 to 0.82g/L), shorter duration of hospital stay (WMD 2.0 days, 95% CI 1.9 to 2.2 days), speedier return to normal activities (WMD 13.6 days, 95% CI 11.8 to 15.4 days), fewer wound or abdominal wall infections (OR 0.32, 95% CI 0.12 to 0.85), fewer unspecified infections or febrile episodes (OR 0.65, 95% CI 0.49 to 0.87), at the cost of longer operating time (WMD 10.6 minutes, 95% CI 7.4 to 13.8 minutes) and more urinary tract (bladder or ureter) injuries (OR 2.61, 95% CI 1.22 to 5.60). There was no evidence of benefits of LH versus VH and the operating time was increased (WMD 41.5 minutes, 95% CI 33.7 to 49.4 minutes). There was no evidence of benefits of LH(a) versus LAVH and the operating time was increased for LH(a) (WMD 25.3 minutes, 95% CI 10.0 to 40.6 minutes). There was statistical heterogeneity in many of the outcome measures when randomised trials were pooled for meta-analysis. No other statistically significant differences were found. However, for some important outcomes, the analyses were underpowered to detect important differences, or they were simply not reported in trials. Data were notably absent for many important long-term outcome measures. Authors' conclusions Significantly improved outcomes suggest VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH, however the length of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when the uterine arteries are divided laparoscopically and laparoscopic approaches require greater surgical expertise. The surgical approach to hysterectomy should be decided by a woman in discussion with her surgeon in light of the relative benefits and hazards. Further research is required with full reporting of all relevant outcomes, particularly important long-term outcomes, in large RCTs, to minimise the possibility of reporting bias. Further research is also required to define the role of the newer approaches to hysterectomy such as TLH.