BACKGROUND: The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH). OBJECTIVES: To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS: We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS: At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS: We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies. AUTHORS' CONCLUSIONS: Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.

/pdf/surgical-approach-to-hysterectomy-for-benign-gynaecological-55zzlqsjex.pdf

Surgical approach to hysterectomy for benign gynaecological disease.

Objective To compare the effects of laparoscopic hysterectomy and abdominal hysterectomy in the abdominal trial, and laparoscopic hysterectomy and vaginal hysterectomy in the vaginal trial. Design Two parallel, multicentre, randomised trials. Setting 28 UK centres and two South African centres. Participants 1380 women were recruited; 1346 had surgery; 937 were followed up at one year. Primary outcome Rate of major complications. Results In the abdominal trial laparoscopic hysterectomy was associated with a higher rate of major complications than abdominal hysterectomy (11.1% v 6.2%, P = 0.02; difference 4.9%, 95% confidence interval 0.9% to 9.1%) and the number needed to treat to harm was 20. Laparoscopic hysterectomy also took longer to perform (84 minutes v 50 minutes) but was less painful (visual analogue scale 3.51 v 3.88, P = 0.01) and resulted in a shorter stay in hospital after the operation (3 days v 4 days). Six weeks after the operation, laparoscopic hysterectomy was associated with less pain and better quality of life than abdominal hysterectomy (SF-12, body image scale, and sexual activity questionnaires). In the vaginal trial we found no evidence of a difference in major complication rates between laparoscopic hysterectomy and vaginal hysterectomy (9.8% v 9.5%, P = 0.92; difference 0.3%, -5.2% to 5.8%), and the number needed to treat to harm was 333. We found no evidence of other differences between laparoscopic hysterectomy and vaginal hysterectomy except that laparoscopic hysterectomy took longer to perform (72 minutes v 39 minutes) and was associated with a higher rate of detecting unexpected pathology (16.4% v 4.8%, P = Conclusions Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy. It also took longer to perform but was associated with less pain, quicker recovery, and better short term quality of life. The trial comparing vaginal hysterectomy with laparoscopic hysterectomy was underpowered and is inconclusive on the rate of major complications; however, vaginal hysterectomy took less time.

https://www.bmj.com/content/bmj/328/7432/129.full.pdf

The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy.

Venous thromboembolism

The gynaecological and obstetric management of women with inherited coagulation disorders requires close collaboration between obstetrician/gynaecologists and haematologists. Ideally these women should be managed in a joint disciplinary clinic where expertise and facilities are available to provide comprehensive assessment of the bleeding disorder and a combined plan of management. The haematologist should arrange and interpret laboratory tests and make provision for appropriate replacement therapy. These guidelines have been provided for healthcare professionals for information and guidance and it is also intended that they are readily available for women with bleeding disorders.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2516.2006.01314.x

The obstetric and gynaecological management of women with inherited bleeding disorders--review with guidelines produced by a taskforce of UK Haemophilia Centre Doctors' Organization.

Summary.  The gynaecological and obstetric management of women with inherited coagulation disorders requires close collaboration between obstetrician/gynaecologists and haematologists. Ideally these women should be managed in a joint disciplinary clinic where expertise and facilities are available to provide comprehensive assessment of the bleeding disorder and a combined plan of management. The haematologist should arrange and interpret laboratory tests and make provision for appropriate replacement therapy. These guidelines have been provided for healthcare professionals for information and guidance and it is also intended that they are readily available for women with bleeding disorders.

The obstetric and gynaecological management of woman with inherited bleeding disorders-review wit guidelinesproduced by a tasjforce of UK Hemophilia Centre Doctors' Organisation

The VALUE national hysterectomy study: description of the patients and their surgery

Severe Complications of Hysterectomy: The Value Study

Two large cohorts of women have been formed in England, Wales, and Northern Ireland to study and compare hysterectomy with endometrial resection and ablation and to provide long-term follow-up information on women who have undergone these treatments (Vaginal, Abdominal, and Laparoscopic Uterine Excision [VALUE]). This article is a report of hysterectomies performed in National Health Service (NHS) and independent hospitals in this area within a 12-month period in 1994 and 1995. Data for the investigation have been collected from all NHS gynecologists and all hospitals within the study area. Hospitals were asked to return monthly forms that provided information on procedures performed within the past month. Information on surgeries was returned 80% of the time from NHS hospitals and 94% of the time from independent hospitals. Eighty percent and 77% of the forms containing patient information were returned from NHS hospitals and independent facilities, respectively. Data was collected for 37,512 hysterectomies, 37,298 of which were eligible for analysis. Only 8% were performed in independent hospitals. The median number of procedures carried out in each NHS hospital was 80; in each independent hospital the median was 18. The median age of the patients was 45 years. Ages ranged from younger that 29 years (2%) to older than 60 years (14%) with the decade from 40 to 49 containing close to one half of the patients (44%). Twenty-four percent were current smokers, but far more younger women currently smoked (49% of those under age 29 years). Dysfunctional uterine bleeding was the most frequent indication for surgery (44 %). In 7% of these cases, uterine fibroids were also an indication. Laparoscopic methods were used in 1145 (3%) of the cases. Eighty-seven percent (997) of these were laparoscopically assisted vaginal surgeries. Eighty-two procedures planned as laparoscopic were converted to abdominal approaches. Two percent of 11,276 planned vaginal hysterectomies were performed abdominally. Forty-three percent of all women undergoing hysterectomy also had oophorectomy performed. More than half of the women who had abdominal or laparoscopic procedures also had their ovaries removed (58% and 59%, respectively). Oophorectomy was performed in 75% of the women between the ages of 40 and 49 years and 90% of the women more than 50 years old. No intraoperative deaths occurred in this series, but eight patients died in the hospital (range, 2-32 days). Another six patients died outside the hospital within 6 weeks of surgery (range, 4-43 days). None of these deaths occurred in patients who had undergone laparoscopic procedures. In all, intraoperative complications occurred in 3.5% of all cases, including 3.37% of abdominal, 3.07% of vaginal, and 6.07% of laparoscopic procedures (P <.001). Respiratory and heart complications occurred in 0.33% to 0.36% of all cases with little difference among the surgical methods. Patients sustained visceral damage (mostly bladder injury) in 0.76% of abdominal, 0.61% of vaginal, and 1.13% of laparoscopic procedures. Major hemorrhage occurred in 2.31% of abdominal, 1.96% of vaginal, and 4.42% of laparoscopic operations (P <.0001). Patients undergoing laparoscopic procedures underwent reoperation related to complications more than twice as often as those having abdominal or vaginal surgery (1.56% compared with 0.73% and 0.75%, respectively; P =.02).

M. A. Metcalfe

Papers

The VALUE national hysterectomy study: description of the patients and their surgery

Severe Complications of Hysterectomy: The Value Study

The VALUE National Hysterectomy Study: Description of the patients and their surgery