Clinical opinion: guidelines for hysterectomy.
OBJECTIVE
Abdominal hysterectomy remains the predominant method of uterine removal in the United States, despite evidence that vaginal hysterectomy offers advantages in regard to operative time, complication rates, return to normal activities, and overall cost of treatment.


METHODS
The predominance of the abdominal approach may be based on factors other than clinical considerations that include resident training, use of obsolete or limited guidelines, a perception rather than a confirmation that pathologic conditions exist that may suggest contraindications to the vaginal approach, misconceptions regarding the cost and safety of vaginal hysterectomy, and increased third-party reimbursement for the abdominal procedure.


RESULTS
Evidence-based practice guidelines that were developed by the Society of Pelvic Reconstructive Surgeons and were adopted by the National Guidelines Clearinghouse have demonstrated that, in a number of studies that span several years, a dramatic shift toward the vaginal approach occurred when the guidelines were applied prospectively.


CONCLUSIONS
The guidelines demonstrate that transvaginal hysterectomy is both feasible and optimal for many patients who long have been considered inappropriate candidates for vaginal hysterectomy. This clinical opinion attempts to address the reasons for the predominant use of the abdominal approach.
Kovac
S Robert
SR
Department of Gynecology and Obstetrics, Emory University School of Medicine, 69 Jesse Hill Jr. Drive SE, Atlanta, GA 30303, USA. skovac@emory.edu
D000465:Algorithms; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000592:standards*; D007045:Hysterectomy, Vaginal / Q000592:standards; D010535:Laparoscopy; D010298:Parity; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D014591:Uterine Diseases / Q000601:surgery*