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.

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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.

The new ESHRE/ESGE classification system of female genital anomalies is presented, aiming to provide a more suitable classification system for the accurate, clear, correlated with clinical management and simple categoriza- tion of female genital anomalies. Congenital malformations of the female genital tract are common miscellaneous de- viations from normal anatomy with health and reproductive consequences. Until now, three systems have been proposed for their categorization, but all of them are associated with serious limitations. The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) have established a common Working Group, under the name CONUTA (CONgenital UTerine Anomalies), with the goal of developing a new updated classification system. A scien- tific committee has been appointed to run the project, looking also for consensus within the scientists working in the field. The new system is designed and developed based on: (1) scientific research through critical review of current proposals and preparation of an initial proposal for discussion between the experts, (2) consensus measurement among the experts through the use of the DELPHI procedure and (3) consensus development by the scientific committee, taking into account the results of the DELPHI procedure and the comments of the experts. Almost 90 participants took part in the process of development of the ESHRE/ESGE classification system, con- tributing with their structured answers and comments. The ESHRE/ESGE classification system is based on anatomy. Anomaliesareclassifiedintothefollowingmainclasses,express- ing uterine anatomical deviations deriving from the same embry- ological origin: U0, normal uterus; U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemi-uterus; U5, aplastic uterus;U6,for still unclassified cases. Main classes have been divided into sub-classes expressing anatomical varieties with clinical significance. Cervical and vaginal anomalies are classified independently into sub-classes having clinical signifi- cance. The ESHRE/ESGE classification of female genital anom- alies seems to fulfil the expectations and the needs of the experts in the field, but its clinical value needs to be proved in everyday practice. The ESHRE/ESGE classification system of female genital anomalies could be used as a starting point for the development of guidelines for their diagnosis and treatment.

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The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies

Objective To evaluate the most appropriate surgical method of hysterectomy (abdominal, vaginal, or laparoscopic) for women with benign disease. Design Systematic review and meta-analysis. Data sources Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, and Biological Abstracts. Selection of studies Only randomised controlled trials were selected; participants had to have benign gynaecological disease; interventions had to comprise at least one hysterectomy method compared with another; and trials had to report primary outcomes (time taken to return to normal activities, intraoperative visceral injury, and major long term complications) or secondary outcomes (operating time, other immediate complications of surgery, short term complications, and duration of hospital stay). Results 27 trials (total of 3643 participants) were included. Return to normal activities was quicker after vaginal than after abdominal hysterectomy (weighted mean difference 9.5 (95% confidence interval 6.4 to 12.6) days) and after laparoscopic than after abdominal hysterectomy (difference 13.6 (11.8 to 15.4) days), but was not significantly different for laparoscopic versus vaginal hysterectomy (difference −1.1 (−4.2 to 2.1) days). There were more urinary tract injuries with laparoscopic than with abdominal hysterectomy (odds ratio 2.61 (95% confidence interval 1.22 to 5.60)), but no other intraoperative visceral injuries showed a significant difference between surgical approaches. Data were notably absent for many important long term patient outcome measures, where the analyses were underpowered to detect important differences, or they were simply not reported in trials. Conclusions Significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it brings a higher chance of bladder or ureter injury.

https://www.bmj.com/content/bmj/330/7506/1478.full.pdf

Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials

Objective
Congenital uterine anomalies are common but their effect on reproductive outcome is unclear. We conducted a systematic review to evaluate the association between different types of congenital uterine anomaly and various reproductive outcomes.

Methods
Searches were performed using MEDLINE, EMBASE, the Cochrane Library and Web of Science. The Newcastle-Ottawa Quality Assessment Scale was used for quality assessment. Uterine defects were grouped into arcuate uteri, canalization defects (septate and subseptate uteri) and unification defects (unicornuate, bicornuate and didelphys uteri). Pooled risk ratios (RR) with 95% confidence intervals (CI) were computed using random effects models.

Results
We identified nine studies comprising 3805 women. Meta-analysis showed that arcuate uteri were associated with increased rates of second-trimester miscarriage (RR, 2.39; 95% CI, 1.33–4.27, P = 0.003) and fetal malpresentation at delivery (RR, 2.53; 95% CI, 1.54–4.18; P < 0.001). Canalization defects were associated with reduced clinical pregnancy rates (RR, 0.86; 95% CI, 0.77–0.96; P = 0.009) and increased rates of first-trimester miscarriage (RR, 2.89; 95% CI; 2.02–4.14; P < 0.001), preterm birth (RR, 2.14; 95% CI, 1.48–3.11; P < 0.001) and fetal malpresentation (RR, 6.24; 95% CI, 4.05–9.62; P < 0.001). Unification defects were associated with increased rates of preterm birth (RR, 2.97; 95% CI, 2.08–4.23; P < 0.001) and fetal malpresentation (RR, 3.87; 95% CI, 2.42–6.18; P < 0.001).

Conclusions
Canalization defects reduce fertility and increase rates of miscarriage and preterm delivery. None of the unification defects reduces fertility but some are associated with miscarriage and preterm delivery. Arcuate uteri are specifically associated with second-trimester miscarriage. All uterine anomalies increase the chance of fetal malpresentation at delivery. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.

https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/uog.10056

Reproductive outcomes in women with congenital uterine anomalies: a systematic review

https://www.fertstert.org/article/S0015-0282(08)00796-6/pdf

Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial

The present randomized study was undertaken in order to compare the short-term results between total laparoscopic hysterectomy and abdominal hysterectomy in a centre with experience in laparoscopic surgery. From January 1997 to September 1998 inclusive, 102 women aged 44-71 years were randomly assigned to either total laparoscopic hysterectomy (n = 51 patients) or abdominal hysterectomy (n = 51 patients). The patients' demographic characteristics were similar in both groups. Average intra-operative blood loss was lower in laparoscopic hysterectomy than in abdominal hysterectomy (P </= 0. 001). The average time employed for laparoscopic hysterectomy was 104.1 +/- 26.98 min; according to the learning curve experienced in this study, the range was 72-163 min and the results after the plateau was reached showed no statistical difference between laparoscopic and abdominal operating times. The mean length of hospital stay was 2.38 +/- 0.30 days in the laparoscopic hysterectomy group versus 6.23 +/- 1.85 days in the abdominal hysterectomy group (P </= 0.001). In conclusion, this study shows that total laparoscopic hysterectomy can be effectively performed within reasonable time limits, provided that operators are experienced surgeons in operative laparoscopy and that operating times are comparable with those of abdominal hysterectomy.

/pdf/total-laparoscopic-hysterectomy-versus-total-abdominal-2wdhnh5ltl.pdf

Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study.

https://www.fertstert.org/article/S0015-0282(13)00742-5/pdf

Renato Venezia

Papers

Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial

Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study.

Detection of oncogenic human papillomavirus genotypes on spermatozoa from male partners of infertile couples

A randomized comparison of endometrial laser intrauterine thermotherapy and hysteroscopic endometrial resection.

Bladder endometriosis: laparoscopic treatment and follow-up.