Hysterectomy…..Which route?

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

Currently, there are five major approaches to hysterectomy for benign gynaecological disease: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robotic-assisted hysterectomy (RH) and vaginal natural orifice hysterectomy (V-NOTES). Within the LH category we further differentiate the laparoscopic-assisted vaginal hysterectomy (LAVH) from the total laparoscopic hysterectomy (TLH) and single-port laparoscopic hysterectomy (SP-LH).

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 their inception to December 2022): the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the trial registries and relevant reference lists, and communicated with experts in the field for any additional trials.

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 and quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvic-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

MAIN RESULTS

We included 63 studies with 6811 women. The evidence for most comparisons was of low or moderate certainty. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (12 RCTs, 1046 women) Return to normal activities was probably faster in the VH group (mean difference (MD) -10.91 days, 95% confidence interval (CI) -17.95 to -3.87; 4 RCTs, 274 women; I2 = 67%; moderate-certainty evidence). This suggests that if the return to normal activities after AH is assumed to be 42 days, then after VH it would be between 24 and 38 days. We are uncertain whether there is a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (28 RCTs, 3431 women) Return to normal activities may be sooner in the LH group (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, 618 women; I2 = 68%, low-certainty evidence), but there may be more urinary tract injuries in the LH group (odds ratio (OR) 2.16, 95% CI 1.19 to 3.93; 18 RCTs, 2594 women; I2 = 0%; moderate-certainty evidence). This suggests that if the return to normal activities after abdominal hysterectomy is assumed to be 37 days, then after laparoscopic hysterectomy it would be between 22 and 25 days. It also suggests that if the rate of ureter injury during abdominal hysterectomy is assumed to be 0.2%, then during laparoscopic hysterectomy it would be between 0.2% and 2%. We are uncertain whether there is a difference between the groups for the other primary outcomes. LH versus VH (22 RCTs, 2135 women) We are uncertain whether there is a difference between the groups for any of our primary outcomes. Both short- and long-term complications were rare in both groups. Robotic-assisted hysterectomy (RH) versus LH (three RCTs, 296 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for our other primary outcomes. Single-port laparoscopic hysterectomy (SP-LH) versus LH (seven RCTs, 621 women) None of the studies reported satisfaction rates, quality of life or major long-term complications. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury. Total laparoscopic hysterectomy (TLH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) (three RCTs, 233 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury or major long-term complications. Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) versus LH (two RCTs, 96 women) We are uncertain whether there is a difference between the groups for rates of bladder injury. Our other primary outcomes were not reported. Overall, adverse events were rare in the included studies.

AUTHORS' CONCLUSIONS

Among women undergoing hysterectomy for benign disease, VH appears to be superior to AH. When technically feasible, VH should be performed in preference to AH because it is associated with faster return to normal activities, fewer wound/abdominal wall infections and shorter hospital stay. Where VH is not possible, LH has advantages over AH including faster return to normal activities, shorter hospital stay, and decreased risk of wound/abdominal wall infection, febrile episodes or unspecified infection, and transfusion. These advantages must be balanced against the increased risk of ureteric injury and longer operative time. When compared to LH, VH was associated with no difference in time to return to normal activities but shorter operative time and shorter hospital stay. RH and V-NOTES require further evaluation since there is a lack of evidence of any patient 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 with the patient and decided in the light of the relative benefits and hazards. Surgical expertise is difficult to quantify and poorly reported in the available studies and this may influence outcomes in ways that cannot be accounted for in this review. In conclusion, when VH is not feasible, LH has multiple advantages over AH, but at the cost of more ureteric injuries. Evidence is limited for RH and V-NOTES.

Comparative Study of Vaginal Hysterectomy and Total Abdominal Hysterectomy in Non-descent Uterus in a Rural Tertiary Care Center

Aim To study the role of vaginal hysterectomy in non-descent uterus and to compare it with abdominal hysterectomy with respect to operative time, intraoperative blood loss and complications, ambulation, and postoperative complications. Materials and methods A prospective non-randomized study was carried out on 200 cases at a rural tertiary care center in B.G. Nagara, Karnataka, India for a period of 18 months after obtaining institutional ethical committee approval. One hundred patients underwent a vaginal hysterectomy, and there other 100 underwent an abdominal hysterectomy for similar indications. Results Mean age, parity, mode of delivery, BMI, uterine size, and anesthesia were similar between the groups. The most common indication was fibroid uterus (50%). It was found that the vaginal hysterectomy group was associated with significantly reduced mean operative duration and a decline in postoperative Hemoglobin when compared to the abdominal hysterectomy group. Patients who underwent vaginal hysterectomy had less postoperative pain and were ambulated earlier and discharged earlier. Also, postoperative complications were more common in those who underwent abdominal hysterectomy. Conclusion Vaginal hysterectomy is a safe and the least invasive route and is associated with lesser complications and should be chosen as the preferred method of hysterectomy, whenever feasible.

A comparative analysis of nondescent vaginal hysterectomy, laparoscopy-assisted vaginal hysterectomy, and total laparoscopic hysterectomy for benign uterine diseases at a rural tertiary care center

Objectives:

The aim of this study was to compare operative data and postoperative complications among nondescent vaginal hysterectomy (NDVH), laparoscopy-assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH) at a rural tertiary care center.

Materials and Methods:

This is a prospective analytical study, of 145 hysterectomies for benign conditions with or without salpingo-oophorectomy in women from 30 to 60 years, over 3 years from January 2016 to December 2019, with 60 cases of NDVH, 46 cases of LAVH, and 39 cases of TLH. The three groups were compared intraoperatively in terms of blood loss, operating time, and intraoperative complications and postoperative complications and postoperative duration of hospital stay.

Results:

There was no significant difference between the three groups in terms of age, parity, body mass index, and indications for hysterectomies. The mean operative time was significantly shorter (P = 0.000) in the NDVH group (54.67 ± 15.67 min) as compared to the LAVH (102.45 ± 10.53 min) and TLH (126.79 ± 8.7 min) groups. Intraoperative blood loss was greater (P = 0.000) in the TLH group (111.025 mL ± 20.8) as compared to the NDVH (59.50 mL ± 16.7) and LAVH (91.85 mL ± 10.66) groups. The intraoperative complications and postoperative complications were higher in the TLH group as compared to the LAVH and NDVH groups. The duration of hospital stay was almost similar in all the groups.

Conclusion:

NDVH may be the preferred approach for experienced surgeons, as it is less time-consuming, has a small amount of blood loss, and is a scarless surgery, whereas LAVH and TLH may be the preferred approaches in the cases of presence of adnexal masses and adhesions or whenever salpingo-oophorectomy is indicated.

A Comparative Study of Non-descent Vaginal Hysterectomy and Laparoscopic Hysterectomy

Objective

To compare intra- and post-op complications between non-descent vaginal hysterectomy and laparoscopic hysterectomy and establish the better method for hysterectomy in non-descent uterus.

Methods

A prospective comparative study of 80 hysterectomies was done over a period of January 2017-Dec 2017, with 40 cases each in one group of non-descent vaginal hysterectomy (NDVH) and other group of total laparoscopic hysterectomy (TLH). Demographic characteristics, co-morbid conditions, indications for surgery, operative time, intra-operative blood loss, post-operative analgesia requirements, post-operative hospital stay and post-operative complications were compared between both groups.

Results

The most common age in both groups was 41-50 years. Fibroid uterus was the most common indication for surgery in both groups. The mean operative time in NDVH group was 40 min while it was 120 min in TLH group, and the mean blood loss in NDVH group was 50 ml, while it was 120 ml in TLH group. P < 0.001 when intraoperative blood loss and operative time were compared between both groups. There were no conversions to laparotomy in NDVH group, while there were three conversions to laparotomy in TLH group. Both groups were similar in post-operative analgesia requirement and post-operative hospital stay. Post-operative complications were similar in both groups.

Conclusions

Non-descent vaginal hysterectomy has advantage over laparoscopic hysterectomy as scarless surgery with fewer complications.

A Prospective Randomized Comparative Study of Vaginal, Abdominal, and Laparoscopic Hysterectomies

PURPOSE

The present study is a prospective, randomized comparative study of abdominal, vaginal and laparoscopic hysterectomies comparing various parameters such as indications, blood loss, post operative pain, time taken for surgery, intraoperative and postoperative complications and total hospital stay.

MATERIALS AND METHODS

50 patients were selected in each group over a period of 18 months. The patients were selected in such a way that they could be operated by all 3 routes. Thus patients undergoing hysterectomy for non malignant conditions, having no adnexal masses, having no severe endometriosis, uterine size not more than 12 weeks and uterine descent of not more than 1st degree were selected.

RESULTS

The most common indication for hysterectomy was found to be DUB, the maximum time taken was in TLH, the minimum blood loss was found in TLH. There was significant difference in the pain scores using VAS among the three groups on day 0 and day 1, where the scores were significantly lower in VH group, the hospital stay was maximum in TAH group while there was no difference between VH and TLH groups.

CONCLUSION

TLH is a better alternative for TAH and with good equipment, expertise and excellent teamwork TLH will be the future candidate for mode of surgery.

Surgical approach to hysterectomy for benign gynaecological disease

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.

Total Vaginal NOTES Hysterectomy: A New Approach to Hysterectomy

The aim of this study was to demonstrate the feasibility of a total hysterectomy performed entirely by transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Conventional, reusable laparoscopic instruments were used, inserted through an inexpensive, self-constructed single-port device. Ten total vaginal NOTES hysterectomies (TVNHs) were performed by a single surgeon. The self-constructed single-port device was made by assembling a surgical glove, a wound protector or modified laryngeal mask airway, 1 reusable 10-mm trocar, and 4 reusable 5-mm trocars. This gloveport was inserted into the vagina to create a pneumovagina. The conventional steps of a vaginal hysterectomy were followed, but performed endoscopically with standard reusable endoscopic instruments. The patient and perioperative data were analyzed. No conversion to standard laparoscopy or laparotomy was necessary in any of the 10 patients who underwent a TVNH. Mean operation time was 97 min (range: 60-120); mean drop in hemoglobin level was 1.5 g/dL (range: 0.5-2.4). There were no operative complications, and postoperative pain scores were very low. This first report on a small number of patients demonstrates that TVNH is possible. By incorporating the advantages of endoscopic surgery, TVNH broadens the indications for vaginal hysterectomy and helps overcome its limitations. At the same time, the NOTES approach avoids abdominal wall wounds and trocar-related complications. TVNH is feasible, even when performed with reusable, conventional laparoscopic instruments. This frugally innovative technique also enables surgeons to perform hysterectomies by vNOTES in low resource settings.