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Evidence summaries

Route of Hysterectomy for Benign Gynaecological Disease

In benign gynaecological diseases, operative time and return to normal daily activities is shorter after vaginal hysterectomy compared to abdominal hysterectomy or laparoscopic hysterectomy. The risk of pelvic organ prolapse may be greater in vaginal hysterectomy compared with abdominal of lapraroscopic route. Level of evidence: "B"

Comment: The certainty of the evidence is downgraded by inconsistency: the I2 statistic is high.

A Cochrane review 1 (abstract , review [Abstract]) included 63 studies with a total of 6 1811 subjects. Return to normal activities was faster in the vaginal hysterectomy (VH) group (mean difference [MD] -10.91 days, 95% CI -17.95 to -3.87; 4 RCTs, n=274; I2 =67% and hospital stay was shorter. Return to normal activities was faster in laparoscopic hysterectomy (LH) group versus abdominal (AH) (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, n=618; I2 =68%), but more urinary tract (bladder or ureter) injuries (OR 2.16, 95% CI 1.19 to 3.93; 18 RCTs, n=2594; I2 =0%). There was no evidence of benefits of laparoscopic versus vaginal hysterectomy (22 RCTs, n=2135). There was a trend of shorter return to normal activites, shorter operation time, and lower costs in the vaginal group compared to the laparoscopic group. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials.

A meta-analysis 2 included 24 RCTs and cohort studies comparing total laparoscopic hysterectomy (LH) with vaginal hysterectomy (VH). There we no difference between the 2 groups for overall complications (OR 1.24, 95% CI 0.68 to 2.28 for major complications and OR 0.83, 95% CI 0.53 to 1.28 for minor complications), risk of ureter and bladder injuries (OR 0.81, 95% CI 0.34 to 1.92), intraoperative blood loss, and length of hospital stay. VH was associated with a shorter operative time (MD 42 minute, 95% CI 29.34 to 55.91) and a lower rate of vaginal cuff dehiscence (OR 6.28, 95% CI 2.38to 16.57) and conversion to laparotomy (OR 3.89, 95% CI 2.18 to 6.95). Costs of procedure were nonsignificantly lower for VH. Patients in the LH group had slightly lower postoperative visual analog scale scores (MD -1.08, 95% CI -1.74 to -0.42).

A Danish nationwide cohort study 3 included 178 282 women hysterectomized for benign conditions. The crude HR for the risk of pelvic organ prolapse (POP) repair after hysterectomy, vaginal hysterectomy (VH) had a 3-fold rise in HR compared to total abdominal hysterectomy (TAH). When restricting the analyses to women without POP at time of hysterectomy, the HR for VH decreased to 1.25. In the subgroup of women without POP at hysterectomy, supravaginal abdominal hysterectomy had a small increase in risk compared to TAH. Laparoscopic hysterectomy had the same risk of POP as TAH.

Clinical comment: The surgical approach to hysterectomy is best decided by a woman in discussion with her surgeon in light of the relative benefits and hazards.

References

  • Pickett CM, Seeratan DD, Mol BWJ, ym. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2023;8(8):CD003677 [PubMed]
  • Sandberg EM, Twijnstra ARH, Driessen SRC et al. Total Laparoscopic Hysterectomy Versus Vaginal Hysterectomy: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2017;24(2):206-217.e22. [PubMed]
  • Lykke R, Løwenstein E, Blaakær J et al. Hysterectomy technique and risk of pelvic organ prolapse repair: a Danish nationwide cohort study. Arch Gynecol Obstet 2017;296(3):527-531. [PubMed]

Primary/Secondary Keywords