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.


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


METHODS
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.


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


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


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.


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.
Nieboer
Theodoor E
TE
Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Johan de Wittlaan, Arnhem, Netherlands, 80 6828 WJ.
Johnson
Neil
N
Lethaby
Anne
A
Tavender
Emma
E
Curr
Elizabeth
E
Garry
Ray
R
van Voorst
Sabine
S
Mol
Ben Willem J
BW
Kluivers
Kirsten B
KB
D005260:Female; D005831:Genital Diseases, Female / Q000601:surgery*; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects / Q000379:methods*; D007045:Hysterectomy, Vaginal / Q000009:adverse effects / Q000379:methods; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D016032:Randomized Controlled Trials as Topic