Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy

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.

Ice-POP: Ice Packs for Postoperative Pain: A Randomized Controlled Trial

STUDY OBJECTIVE

To evaluate the benefit of ice packs as a supplement to standard pain management following laparoscopic hysterectomy (LH).

DESIGN

This Institutional Review Board-approved randomized controlled trial involved patients undergoing LH for benign conditions. Subjects were randomized to receive standard enhanced recovery after surgery pain management or standard enhanced recovery after surgery plus ice packs.

SETTING

Two academic tertiary care centers PATIENTS: Patients undergoing planned outpatient LH with the minimally invasive gynecologic surgery team between February 2019 and November 2020 were considered. Patients with chronic pain, current opioid use ≥1 week, or planned overnight hospitalizations were excluded. Primary outcome data were available for 51 subjects (24 control, 27 intervention).

INTERVENTIONS

Ice packs were placed on the abdomen in the operating room.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed at multiple time points throughout the study using a visual analogue scale (VAS). Opioid requirement was assessed using morphine milligram equivalent. There was no difference between the groups on any demographic variables. Morphine milligram equivalent requirements were also not different between the groups (p = .63). Postoperative day 1 (POD#1) VAS scores were not different (p = .89). Eighty-five percent of subjects reported feeling that their pain was controlled. Subjects who reported that they did not feel their pain was controlled did not use more opioids on POD#1 (p = .37), nor did they have higher POD#1 VAS scores (p = .55). Eighty-seven percent of the intervention subjects said they would use ice again, and 82.6% of them said they would recommend ice to others. There were no adverse events related to ice. All subjects were prescribed 20 tablets oxycodone and averaged 2.9 (SD 3.4) tablets used after discharge.

CONCLUSION

Ice packs are an acceptable supplement for postoperative pain control, but they do not reduce postoperative pain or opioid usage compared to standard pain management without ice packs.

Impact of Laparoscopic Hysterectomy on Quality of Life

There is an ongoing debate regarding the benefits and drawbacks of the various routes of hysterectomy. A number of studies have examined overall quality of life outcomes as well as specific patient-reported outcomes including physical, psychosocial, and sexual functioning after hysterectomy. Existing studies have used varied methodologies with widely heterogeneous results, but patient satisfaction appears to be very high after laparoscopic hysterectomy, with many studies favoring the laparoscopic approach over other routes of hysterectomy. There are many opportunities for further investigation into the impact of laparoscopic hysterectomy on quality of life-an outcome measure that may be 1 of the most important in surgeries for benign indications.

No. 109-Hysterectomy

OBJECTIVE

To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully.

OPTIONS

The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners.

OUTCOMES

Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits.

EVIDENCE

Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.

BENEFITS, HARMS, AND COSTS

Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery.

RECOMMENDATIONS

Benign Disease Preinvasive Disease Invasive Disease Acute Conditions Other Indications Surgical Approach VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada.

Finding the Value of Minimally Invasive Gynecologic Surgery

Minimally invasive surgery is indistinctly defined and some cases possess clinical outcomes that are similarly indistinct or excessively costly. Seeking to clarify these issues will offer organized medicine an opportunity to deliver value-based health care. Context (patient, society, and clinician) is critical to finding that clarity, although the clinician context likely offers the best insights into how the ideal of high-value care may be incorporated into minimally invasive gynecologic surgery.

Management considerations for patients with uterine fibroids and concurrent venous thromboembolism

PURPOSE OF REVIEW

The purpose is to provide an update on management strategies for uterine fibroids in the setting of venous thromboembolism (VTE).

RECENT FINDINGS

Uterine fibroids and VTE are independently associated with morbidity and increasing healthcare costs. Women with large uterine fibroids have a higher likelihood of VTE. Current strategies for stratifying patients with VTE take into account the nature of the VTE (i.e., truly provoked or unprovoked) and many patients may only require short-term anticoagulation. In those patients with risk factors for recurrent VTE, longer term anticoagulation may be required.

SUMMARY

In women with large uterine fibroids, the likelihood of concurrent VTE increases. Peri and postoperative management should be determined based on patient-specific risk stratification, with the majority of patients requiring short-term anticoagulation. Further risk stratification may be required for patients with essentially an unprovoked VTE, and consultation with a thrombosis specialist is recommended.

Cost evaluation, quality of life and pelvic organ function of three approaches to hysterectomy for benign uterine conditions: study protocol for a randomized controlled trial

BACKGROUND

Hysterectomy is the commonest major gynaecological surgery. Although there are many approaches to hysterectomy, which depend on clinical criteria, certain patients may be eligible to be operated in any of the several available approaches. However, most comparative studies on hysterectomy are between two approaches. There is also a relative absence of data on long-term outcomes on quality of life and pelvic organ function. There is no single study which has considered quality of life, pelvic organ function and cost-effectiveness for the three main types of hysterectomy. Therefore, the objective of this study is to provide evidence on the optimal route of hysterectomy in terms of cost-effectiveness by way of a three-armed randomized control study between non-descent vaginal hysterectomy, total laparoscopic hysterectomy and total abdominal hysterectomy.

METHODS

A multicentre three-armed randomized control trial is being conducted at the professorial gynaecology unit of the North Colombo Teaching Hospital, Ragama, Sri Lanka and gynaecology unit of the District General Hospital, Mannar, Sri Lanka. The study population is women needing hysterectomy for non-malignant uterine causes. Patients with a uterus > 14 weeks, previous pelvic surgery, those requiring incontinence surgery or pelvic floor surgery, any medical illness which caution/contraindicate laparoscopic surgery and who cannot read and write will be excluded. The main exposure variable is non-descent vaginal hysterectomy and total laparoscopic hysterectomy. The control group will be patients undergoing total abdominal hysterectomy. The primary outcome is time to recover following surgery, which is the earliest time to resume all of the usual activities done prior to surgery. In total, 147 patients (49 per arm) are needed to have 80% power at α-0.01 considering a loss to follow-up of 20% to detect a 7-day difference between the three routes; TLH versus TAH versus NDVH. The economic evaluation will take a societal perspective and will include direct costs in relation to allocation of healthcare resources and indirect costs which are borne by the patient. A micro-costing approach will be adopted to calculate direct costs from the time of presentation to the gynaecology clinic up to 6 months after surgery. Incremental cost-effectiveness ratios (ICER) will be obtained by calculating the incremental costs divided by the incremental effects (time to recover and QALYs gained) for the intervention groups (NDVH and TLH) over the standard care (TAH) group.

DISCUSSION

The cost of the procedure, quality of life and pelvic organ function following the three main routes of hysterectomy are important to clinicians and healthcare providers, both in developed and developing countries.

TRIAL REGISTRATION

The study was registered in the Sri Lanka clinical trials registry (SLCTR/2016/020) and the International Clinical Trials Registry Platform ( U1111-1194-8422 ) on 26 July 2016.

Economic and Survival Implications of Use of Electric Power Morcellation for Hysterectomy for Presumed Benign Gynecologic Disease

BACKGROUND

Electric power morcellation during laparoscopic hysterectomy allows some women to undergo minimally invasive surgery but may disrupt underlying occult malignancies and increase the risk of tumor dissemination.

METHODS

We developed a state transition Markov cohort simulation model of the risks and benefits of hysterectomy (abdominal, laparoscopic, and laparoscopic with electric power morcellation) for women with presumed benign gynecologic disease. The model considered perioperative morbidity, mortality, risk of cancer and dissemination, and outcomes in women with an underlying malignancy. We explored the effectiveness from a societal perspective stratified by age (<40, 40-49, 50-59, and ≥60 years).

RESULTS

Under all scenarios, modeled laparoscopic hysterectomy without morcellation was the most beneficial strategy. Laparoscopic hysterectomy with morcellation was associated with 80.83 more intraoperative complications, 199.64 fewer perioperative complications, and 241.80 fewer readmissions than abdominal hysterectomy per 10 000 women. Per 10 000 women younger than age 40 years, laparoscopic hysterectomy with morcellation was associated with 1.57 more cases of disseminated cancer and 0.97 fewer deaths than abdominal hysterectomy. The excess cases of disseminated cancer per 10 000 women with morcellation compared with abdominal hysterectomy increased with age to 47.54 per 10 000 in women age 60 years and older. Compared with abdominal hysterectomy, this resulted in 0.30 (age 40-49 years), 5.07 (age 50-59 years), and 18.14 (age 60 years and older) excess deaths per 10 000 women in the respective age groups.

CONCLUSION

Laparoscopic hysterectomy without morcellation is the most beneficial approach of the three methods of hysterectomy studied. In older women, the risks of electric power morcellation may outweigh the benefits of minimally invasive hysterectomy.

Vaginal hysterectomy vs. laparoscopically assisted vaginal hysterectomy in women with symptomatic uterine leiomyomas: a retrospective study

Introduction

Uterine leiomyomas are the most common benign tumors of the female reproductive system. Although the majority of myomas are asymptomatic, some patients have symptoms or signs of varying degrees and require a hysterectomy.

The aim of the study

The aim of the study was to compare the clinical results of two minimally invasive hysterectomy techniques: vaginal hysterectomy (VH) and laparoscopically assisted vaginal hysterectomy (LAVH).

Material and methods

A retrospective, observational study was performed at a tertiary care center: the Gynecology and Gynecologic Oncology Department, Polish Mother's Memorial Hospital Research Institute. The study period was from January 2003 to December 2012. A total of 159 women underwent either vaginal hysterectomy (VH, n = 120) or laparoscopically assisted vaginal hysterectomy (LAVH, n = 39) for symptomatic uterine myomas. Outcome measures, including past medical history, blood loss, major complications, operating time and discharge time were assessed and compared between the studied groups. Statistical analysis was performed using Student t-test, U-Mann Whitney test, χ² test and Yates‘χ² test. P < 0.05 was considered statistically significant.

Results

There were no differences in patients’ mean age. Parity was significantly higher in the VH group (VH 1.9 ± 0.7 vs. LAVH 1.5 ± 0.8; p = 0.008). No difference was found in the mean ± standard deviation (SD) uterine volume between vaginal hysterectomy and LAVH groups (179 ± 89 vs. 199 ± 88 cm³), respectively. The mean operative time was significantly longer for the LAVH group (83 ± 29 vs. 131 ± 30 min; p = 0.0001). The intraoperative blood loss (VH 1.3 ± 1.1 vs. LAVH 1.4 ± 0.9 g/dl; p = 0.2) and the rate of intra- and postoperative complications were similar in both groups studied. The mean discharge time was longer for LAVH than for VH (VH 4.2 ± 1.2 vs. LAVH 5.3 ± 1.3 days, p = 0.0001).

Conclusions

Laparoscopically assisted vaginal hysterectomy and VH are safe hysterectomy techniques for women with the myomatous uterus. Concerning the LAVH, the abdominal-pelvic exploration and the ability to perform adnexectomy safely represent the major advantages comparing with VH. Vaginal hysterectomy had a shorter operating time and the mild blood loss making it a suitable method of hysterectomy for cases in which the shortest duration of surgery and anesthesia is preferable.

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.

Milestones to optimal adoption of robotic technology in gynecology

Minimally invasive technology, especially robotics, is gaining widespread acceptance and is becoming the standard approach for the treatment of both benign and malignant gynecologic conditions in centers across the country. However, there are challenges on a systems-based level to the implementation of a robotic program. Prominent among the concerns is the length of the learning curve, team-building, quality of life, and financial and various organizational challenges. The purpose of this review article is to address those challenges as milestones on the progress to a successful robotics program and explore possible solutions.

A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy

OBJECTIVE

The purpose of this study was to compare operative time and intra- and postoperative complications between total laparoscopic hysterectomy and robotic-assisted total laparoscopic hysterectomy.

STUDY DESIGN

This study was a blinded, prospective randomized controlled trial conducted at 2 institutions. Subjects consisted of women who planned laparoscopic hysterectomy for benign indications. Preoperative randomization to total laparoscopic hysterectomy or robotic-assisted total laparoscopic hysterectomy was stratified by surgeon and uterine size (> or ≤12 weeks). Validated questionnaires, activity assessment scales, and visual analogue scales were administered at baseline and during follow-up evaluation.

RESULTS

Sixty-two women gave consent and were enrolled and randomly assigned; 53 women underwent surgery (laparoscopic, 27 women; robot-assisted, 26 women). There were no demographic differences between groups. Compared with laparoscopic hysterectomy, total case time (skin incision to skin closure) was significantly longer in the robot-assisted group (mean difference, +77 minutes; 95% confidence interval, 33-121; P < .001] as was total operating room time (entry into operating room to exit; mean difference, +72 minutes; 95% confidence interval, 14-130; P = .016). Mean docking time was 6 ± 4 minutes. There were no significant differences between groups in estimated blood loss, pre- and postoperative hematocrit change, and length of stay. There were very few complications, with no difference in individual complication types or total complications between groups. Postoperative pain and return to daily activities were no different between groups.

CONCLUSION

Although laparoscopic and robotic-assisted hysterectomies are safe approaches to hysterectomy, robotic-assisted hysterectomy requires a significantly longer operative time.

Robotic versus laparoscopic hysterectomy: a review of recent comparative studies

PURPOSE OF REVIEW

To illustrate the current stand on robotic versus conventional laparoscopic hysterectomy regarding operating times, clinical outcome and costs.

RECENT FINDINGS

Only six studies were reviewed, as there are only few recent studies comparing robotic with laparoscopic hysterectomy and most are retrospective. Apart from one multicentre study with over 36  000 patients, 350 institutions and numerous surgeons, most studies were performed with few cases by one or two surgeons at one or two hospitals. Operating times for robotic hysterectomies generally were longer, ranging from 89.9 to 267  min. Surgery time for conventional laparoscopic hysterectomies was between 83 and 206  min. In all studies, clinical outcomes such as blood loss, complications or hospital stay of both the robotic and the conventional laparoscopic procedure were similar. Only two studies compared costs and both came up with very similar findings. Cost for a robot-assisted hysterectomy is approximately 2600 USD higher than that for conventional laparoscopic hysterectomy not including investment and amortization.

SUMMARY

Robotic and conventional laparoscopic hysterectomy are essentially equivalent regarding surgical and clinical outcome. Operating times are slightly higher and costs are significantly higher for the robotic procedure.

Indication for laparoscopically assisted vaginal hysterectomy

When uterine weight is greater than 800 grams, total abdominal hysterectomy is more appropriate than laparoscopic-assisted vaginal hysterectomy.

Objectives:

Total hysterectomy procedures include total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), and laparoscopically assisted vaginal hysterectomy (LAVH). Our institution has introduced LAVH as a preferred option to the more invasive TAH. To date, no reports have proposed surgical indications for LAVH based on statistical analysis of surgical results. The purpose of this study was to establish criteria for performing LAVH through statistical analysis of a retrospective review of surgical outcomes in LAVH cases at our institution over a period of 15 years.

Methods:

The medical records of 629 patients scheduled for LAVH for uterine fibroids and/or adenomyosis at our hospital were examined. Surgical results (blood loss, operative time, rates of conversion to laparotomy, and intra- and postoperative complications) were compared among 9 groups classified by uterine weight.

Results:

Statistically significant differences in surgical outcomes were found between the group with a uterine weight ≥800g and the other groups.

Conclusion:

We found that when the uterine weight was ≥800g, TAH was more appropriate because significant blood loss and/or complications would be expected during LAVH. A removed uterus weighing 800g is reportedly equivalent to a preoperative uterine size of approximately 12cm. Therefore, LAVH may be safely indicated for patients with a uterine size ≤12cm (approximately equivalent to the uterine size at 16-weeks gestation).

Total abdominal hysterectomy versus laparoscopically-assisted vaginal hysterectomy versus total vaginal hysterectomy

INTRODUCTION

While total abdominal hysterectomy (TAH) and total vaginal hysterectomy (TVH) are conventional procedures, we have actively introduced laparoscopically-assisted vaginal hysterectomy (LAVH) since its advent. This study was the first attempt to retrospectively compare the surgical results, including invasiveness, among the three methods of performing a hysterectomy.

METHODS

The subjects included 1181 patients who underwent total hysterectomies (TAH, n=465; LAVH, n=629; TVH, n=87) due to uterine fibroids or uterine adenomyosis at our hospital between January 1995 and December 2009. The mean age, parity, weight of the removed uterus, operative time, blood loss, rates of intra- and post-operative complications, length of post-operative hospital stay, leukocyte count, and CRP and hemoglobin levels were compared.

RESULTS

The operative time was significantly longer in the LAVH group than the other two groups. Blood loss was significantly greater in the TAH group than the LAVH and TVA groups. The rates of intra- and post-operative complications were significantly higher in the TAH group than the LAVH group. The CRP level and leukocyte count were significantly lower in the LAVH group than the TAH and TVH groups.

CONCLUSION

LAVH can be applied to nulligravidas or patients with relatively large uteri and it is proved less invasive than TAH and TVH in this study. We recommend active application of LAVH.

Multidisciplinary convalescence recommendations after gynaecological surgery: a modified Delphi method among experts

OBJECTIVE

To generate structured detailed uniform convalescence recommendations after gynaecological surgery by a modified Delphi method amongst experts and a representative group of physicians.

DESIGN

Modified Delphi study.

SETTING

Expert physicians recruited by their respective medical boards and employed at different hospitals, doctor's surgeries and healthcare services.

POPULATION

Twelve experts (five gynaecologists, two general practitioners [GPs] and five occupational physicians [OPs]) and a representative sample of 63 medical doctors.

METHODS

Multidisciplinary detailed recommendations for graded resumption of relevant activities after uncomplicated hysterectomy (laparoscopic supracervical, total laparoscopic/laparoscopic-assisted, vaginal and abdominal hysterectomies) and laparoscopic adnexal surgery were developed. Recommendations were based on a literature review and a modified Delphi procedure among 12 experts, recruited in collaboration with the participating medical boards of gynaecologists, GPs and OPs.

MAIN OUTCOME MEASURES

A multidisciplinary consensus of at least 67% on the relevant detailed convalescence recommendations in relation to hysterectomy and laparoscopic adnexal surgery.

RESULTS

Out of initially 65 activities, the expert panel judged 38 activities relevant for convalescence recommendations. Consensus for all activities was achieved after four Delphi rounds and two group discussions. The recommendations were judged as feasible by a representative sample of 26 gynaecologists, 19 GPs and 18 OPs.

CONCLUSIONS

Consensus between gynaecologists, GPs and OPs was achieved on all relevant convalescence recommendations regarding hysterectomy (abdominal, vaginal and laparoscopic) and laparoscopic adnexal surgery.

Safe laparoscopic removal of a 3200 gram fibroid uterus

BACKGROUND AND OBJECTIVES

Hysterectomy using minimally invasive techniques yields fewer complications, less blood loss, and quicker recovery time compared with traditional abdominal hysterectomy. Despite these advantages, 65% of all hysterectomies in the United States are still performed using traditional laparotomy, and many clinicians still exclude patients with a history of prior abdominal surgery, significant obesity, or a large fibroid uterus from these procedures. Among physicians skilled in minimally invasive surgery, the prior largest uteri removed included a 2421g uterus removed vaginally, and a 2418g uterus removed via hand-assisted laparoscopic hysterectomy.

METHODS

We performed a laparoscopic-assisted hysterectomy on a significantly obese 50-year-old woman with a 3200g uterus. The patient required a 2-day hospital stay and recovered unremarkably. The patient was able to return to work within one week and quickly returned to activities of daily life.

CONCLUSION

In the hands of experienced minimally invasive surgeons, laparotomy can be avoided in almost all instances of hysterectomy for benign disease.

Cost effectiveness of laparoscopy versus laparotomy in early stage endometrial cancer: a randomised trial

OBJECTIVE

To determine the cost effectiveness of total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH) in early stage endometrial cancer alongside a multicenter randomised controlled trial (RCT).

METHODS

An economic analysis was conducted in 279 patients (TLH n=185; TAH n=94) with early stage endometrial cancer from a societal perspective, including all relevant costs over a three month time horizon. Health outcomes were expressed in terms of major complication-free rate and in terms of utility based on women's response to the EQ-5D. Comparisons of costs per major complication-free patient gained and costs with utility gain and costs were made, using incremental cost effectiveness ratios.

RESULTS

The mean major complication-free rate and median utility scores were comparable between TLH and TAH at three months. TLH is more costly intraoperatively (Δ$1.129) and less costly postoperatively in-hospital (Δ$-1.350) compared to TAH. Incremental costs per major complication-free patient were $-52. Higher cost ($249) were generated while no gains in utility (-0.02) were observed for TLH compared to TAH. Analysing utility at six weeks, incremental costs per additional point on the EQ-5D scale were $1.617.

CONCLUSION

TLH is cost effective compared to TAH, based on major complication-free rate as measure of effect. Along with future cost saving strategies in laparoscopy, TLH is assumed to be cost effective for both effect measures. Therefore and due to comparable safety, TLH should be recommended as a standard-of-care surgical procedure in early endometrial cancer.

Comparison of minimally invasive surgical approaches for hysterectomy at a community hospital: robotic-assisted laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy and laparoscopic supracervical hysterectomy

The study reported here compares outcomes of three approaches to minimally invasive hysterectomy for benign indications, namely, robotic-assisted laparoscopic (RALH), laparoscopic-assisted vaginal (LAVH) and laparoscopic supracervical (LSH) hysterectomy. The total patient cohort comprised the first 237 patients undergoing robotic surgeries at our hospital between August 2007 and June 2009; the last 100 patients undergoing LAVH by the same surgeons between July 2006 and February 2008 and 165 patients undergoing LAVHs performed by nine surgeons between January 2008 and June 2009; 87 patients undergoing LSH by the same nine surgeons between January 2008 and June 2009. Among the RALH patients were cases of greater complexity: (1) higher prevalence of prior abdominopelvic surgery than that found among LAVH patients; (2) an increased number of procedures for endometriosis and pelvic reconstruction. Uterine weights also were greater in RALH patients [207.4 vs. 149.6 (LAVH; P < 0.001) and 141.1 g (LSH; P = 0.005)]. Despite case complexity, operative time was significantly lower in RALH than in LAVH (89.9 vs. 124.8 min, P < 0.001) and similar to that in LSH (89.6 min). Estimated blood loss was greater in LAVH (167.9 ml) than in RALH (59.0 ml, P < 0.001) or LSH (65.7 ml, P < 0.001). Length of hospital stay was shorter for RALH than for LAVH or LSH. Conversion and complication rates were low and similar across procedures. Multivariable regression indicated that LAVH, obesity, uterine weight ≥250 g and older age predicted significantly longer operative time. The learning curve for RALH demonstrated improved operative time over the case series. Our findings show the benefits of RALH over LAVH. Outcomes in RALH can be as good as or better than those in LSH, suggesting the latter should be the choice primarily for women desiring cervix-sparing surgery.

Robotically assisted hysterectomy: 100 cases after the learning curve

To report on perioperative outcomes of robotic hysterectomy after the learning curve, we performed a retrospective review of our second 100 consecutive robotic hysterectomies performed by two surgeons between January 2007 and February 2008. Operative time following our learning curve was 79.3 ± 36.1 min. Patient age was 44.2 ± 9.6 years, body mass index (BMI) was 30.9 ± 8.3 kg/m(2), and uterine weight was 223.7 ± 195.8 g. Indications for surgery included fibroids, menstrual disorders, and endometriosis. We performed total robotic-assisted laparoscopic hysterectomy type IVE. There were no conversions, no blood transfusions, and one cystotomy, repaired intraoperatively. Blood loss was 68.8 ± 105.8 cc, and average length of stay was 1.1 ± 0.3 days. There were no postoperative complications. Perioperative outcomes demonstrate low average operative times with a high level of safety on a broadened patient population, suggesting a potential advantage to using the robotic platform.

Hybrid natural orifice transluminal endoscopic surgery for nephrectomy with standard laparoscopic instruments: experience in a canine model

OBJECTIVE

The aim of this study was to demonstrate the feasibility of hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with standard laparoscopic instruments through a modified vaginal trocar in a canine model.

MATERIALS AND METHODS

Ten cross-bred adult female dogs were used for right (n = 4) and left (n = 6) transvaginal nephrectomy. After transumbilical peritoneoscopy, a laparoscopic transvaginal trocar was introduced through the posterior vaginal fornix under direct vision. Using a 10-mm working laparoscope lens with a 3-mm working channel as endovision via the umbilical port and the transvaginal port, triangulation and dissection of the kidney and its hilum were performed. The renal artery and vein were closed with Hem-o-lok clips transvaginally. At the end of the procedure, after snaring the kidney in an endobag, the specimen was retrieved through a colpotomy incision by extending the vaginal port site.

RESULTS

All procedures were completed without need for conversion. The mean operative time was 101 minutes (75-135 minutes). The mean preoperative/postoperative hemoglobin was 12.01/11.7 g/dL and intraoperative blood loss was minimal. The mean size of the removed kidneys was 9.1 x 5.1 cm and the mean weight was 98.5 g (90-115 g). Exploration of the abdomen and vagina after 1 month showed complete healing of the colpotomy incision with no visceral injury. There were no significant adhesions or fibrotic changes in the renal fossa.

CONCLUSION

Hybrid NOTES nephrectomy is technically feasible in canine model with a standard laparoscopic setup and instruments. This study may remove barriers for further investigational work with NOTES technique, especially with a view to adapting it for use in low-resource centers, while offering a strategy to help surgeons train with this novel technology.

Costs and effects of abdominal versus laparoscopic hysterectomy: systematic review of controlled trials

Objective

Comparative evaluation of costs and effects of laparoscopic hysterectomy (LH) and abdominal hysterectomy (AH).

Data sources

Controlled trials from Cochrane Central register of controlled trials, Medline, Embase and prospective trial registers.

Selection of studies

Twelve (randomized) controlled studies including the search terms costs, laparoscopy, laparotomy and hysterectomy were identified.

Methods

The type of cost analysis, perspective of cost analyses and separate cost components were assessed. The direct and indirect costs were extracted from the original studies. For the cost estimation, hospital stay and procedure costs were selected as most important cost drivers. As main outcome the major complication rate was taken.

Findings

Analysis was performed on 2226 patients, of which 1013 (45.5%) in the LH group and 1213 (54.5%) in the AH group. Five studies scored ≥10 points (out of 19) for methodological quality. The reported total direct costs in the LH group ($63,997) were 6.1% higher than the AH group ($60,114). The reported total indirect costs of the LH group ($1,609) were half of the total indirect in the AH group ($3,139). The estimated mean major complication rate in the LH group (14.3%) was lower than in the AH group (15.9%). The estimated total costs in the LH group were $3,884 versus $3,312 in the AH group. The incremental costs for reducing one patient with major complication(s) in the LH group compared to the AH group was $35,750.

Conclusions

The shorter hospital stay in the LH group compensates for the increased procedure costs, with less morbidity. LH points in the direction of cost effectiveness, however further research is warranted with a broader costs perspective including long term effects as societal benefit, quality of life and survival.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions depending on the part of the procedure performed laparoscopically.

OBJECTIVES

To assess the most beneficial and least harmful surgical approach to hysterectomy for women with benign gynaecological conditions.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (15 August 2008), CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), EMBASE (1980 to August 2008), Biological Abstracts (1969 to August 2008), the National Research Register, and relevant citation lists.

SELECTION CRITERIA

Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included.

DATA COLLECTION AND ANALYSIS

Independent selection of trials and data extraction were employed following Cochrane guidelines.

MAIN RESULTS

There were 34 included studies with 4495 women. The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections (odds ratio (OR) 0.42), and shorter duration of hospital stay (MD 1.1 days). The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections (OR 0.31) at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection (OR 3.77) and shorter operation time (MD 25.3 minutes). There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding (OR 2.76) were increased in LH. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials. Data were absent for many important long-term outcome measures.

AUTHORS' CONCLUSIONS

Because of equal or significantly better outcomes on all parameters, 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. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards.

The effects of laparoscopic surgery and nosocomial infections on the cost of care: evidence from three common surgical procedures

OBJECTIVE

To examine the cost of care for laparoscopic versus open surgery and the added cost of nosocomial infections for three common surgical procedures: cholecystectomy, hysterectomy, and appendectomy.

METHODS

The Cardinal Health database repository was utilized to extract reimbursement data for laparoscopic and open cholecystectomy, hysterectomy, and appendectomy surgical procedures. Utilizing a 22-hospital sample and a Health Insurance Portability and Accountability Act compliant clinical data extraction technique, the Cardinal Health database repository produced a Nosocomial Infection Marker to identify and track nosocomial infection rates for these procedures. ICD-9 codes were utilized to identify 10,731 patients who had undergone these procedures between September 2004 and December 2006. Multivariable linear regression models were estimated to isolate the effects of laparoscopic versus open surgery and nosocomial infections on the cost of care.

RESULTS

Laparoscopic surgery significantly reduces the overall cost of care for cholecystectomies, hysterectomies, and appendectomies. Controlling for the cost of nosocomial infection, incremental cost savings from laparoscopic versus open surgery for all three procedures average $1608. Cholecystectomy has the largest savings ($3299), followed by hysterectomy ($1385) and appendectomy ($1032). These cost savings in part reflect that patients undergoing laparoscopic procedures have shorter lengths of stay. In contrast, nosocomial infection increases costs substantially for each surgery type, raising costs for cholecystectomy by $4794, hysterectomy by $4528, and appendectomy by $6108.

CONCLUSION

The cost of care for laparoscopic surgery is lower than open surgery for cholecystectomy, hysterectomy, and appendectomy. This conclusion is based on actual hospital reimbursement data.

Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery

OBJECTIVE

To investigate the need for further surgery after laparoscopic excision of endometriosis or hysterectomy.

METHODS

In this retrospective study, women who had surgery for endometriosis-associated pain at the Cleveland Clinic were assessed for requirement for subsequent surgery. One hundred twenty patients who underwent hysterectomy with or without oophorectomy for endometriosis and 120 patients who had laparoscopic excision of their endometriotic lesions only (local excision group) formed the study population. Estimates of reoperation-free survival at 2, 5, and 7 years were calculated using Kaplan-Meier methods, and estimates of risk (hazard ratios) were computed using Cox proportional hazards models. A significance level of .05 was assumed for all tests.

RESULTS

In women who underwent local excision with ovarian preservation, the surgery-free percentages were 79.4%, 53.3%, and 44.6%, respectively, at 2, 5, and 7 years. In women who underwent hysterectomy with ovarian preservation, the 2-, 5-, and 7-year reoperation-free percentages were 95.7%, 86.6%, and 77.0%, respectively. In women who underwent hysterectomy without ovarian preservation, the percentages were 96.0%, 91.7%, and 91.7%, respectively. However, in women between 30 and 39 years of age, removal of the ovaries did not significantly improve the surgery-free time.

CONCLUSION

Local excision of endometriosis is associated with good short-term outcomes but, on long-term follow-up, has a high reoperation rate. Hysterectomy is associated with a low reoperation rate. Preservation of the ovaries at the time of hysterectomy remains a viable option.

LEVEL OF EVIDENCE

II.

Factors associated with postoperative recovery after laparoscopic and abdominal hysterectomy

OBJECTIVES

To determine whether the day-by-day recovery of general wellbeing was faster in women undergoing laparoscopic hysterectomy than in total abdominal hysterectomy and to analyse the association between stress coping and sick-leave and the day-by-day recovery measured as general wellbeing.

STUDY DESIGN

A randomised multicentre trial conducted in five hospitals in the South East of Sweden. Hundred and twenty-five women scheduled for hysterectomy for benign conditions were enrolled in the study and 117 women completed the study. Fifty-five women were randomised to abdominal hysterectomy and 62 to laparoscopic hysterectomy. Day-by-day recovery of general wellbeing was measured by a visual analogue scale 1 week preoperatively, 35 days postoperatively, and during 1 week 6 months postoperatively. Stress-coping capability was measured preoperatively using a specific psychometric measurement. Sick-leave was granted with an initial period of 14 days and prolonged on patient demand with 7 days periods. Effects of operating method and stress-coping ability on the day-by-day recovery adjusted for postoperative complications and analgesics were analysed by means of analysis of variance for repeated measurements.

RESULTS

No significant difference was found in the day-by-day recovery of the general wellbeing between the operating methods. Stress-coping ability did significantly influence the day-by-day recovery of general wellbeing. Duration of sick-leave was associated with the occurrence of postoperative complications but not with stress-coping ability.

CONCLUSIONS

The day-by-day recovery of general wellbeing is not faster in laparoscopic hysterectomy than in abdominal hysterectomy. Women with high stress-coping abilities have a better outcome in general wellbeing than women with low stress-coping capacity. Identification of women with low stress-coping abilities and prevention of complications might be of benefit for improving postoperative wellbeing.