title: Postoperative outcomes and quality of life following hysterectomy by natural orifice transluminal endoscopic surgery (NOTES) compared to laparoscopy in women with a non-prolapsed uterus and benign gynaecological disease: a systematic review and meta-analysis.
abstract: OBJECTIVE
  To critically appraise studies comparing benefits and harms in women with benign disease without prolapse undergoing hysterectomy by natural orifice transluminal endoscopic surgery (NOTES) versus laparoscopy.
  
  
  METHODS
  We followed the PRISMA guidelines. We searched MEDLINE, EMBASE and CENTRAL for randomised controlled trials (RCTs), controlled clinical trials (CCTs) and cohort studies comparing NOTES with laparoscopy assisted vaginal hysterectomy (LAVH) or total laparoscopic hysterectomy (TLH) in women bound to undergo removal of a non-prolapsed uterus for benign disease. Two authors searched and selected studies, extracted data and assessed the risk of bias independently. Any disagreement was resolved by discussion or arbitration.
  
  
  RESULTS
  We did not find RCTs but retrieved two retrospective cohort studies comparing NOTES with LAVH. The study quality as assessed by the Newcastle-Ottawa scale was acceptable. Both studies reported no conversions. The operative time in women treated by NOTES was shorter compared to LAVH: the mean difference (MD) was -22.04min (95% CI -28.00min to -16.08min; 342 women; 2 studies). There were no differences for complications in women treated by NOTES compared to LAVH: the risk ratio (RR) was 0.57 (95% CI 0.17-1.91; 342 women; 2 studies). The length of stay was shorter in women treated by NOTES versus LAVH: the MD was -0.42days (95% CI -0.59days to -0.25days; 342 women; 2 studies). There were no differences for the median VAS scores at 12h between women treated by NOTES (median 2, range 0-6) or by LAVH (median 2, range 0-6) (48 women, 1 study). There were no differences in the median additional analgesic dose request in women treated by NOTES (median 0, range 0-6) or by LAVH (median 1, range 0-5) (48 women, 1 study). The hospital charges for treatment by NOTES were higher compared to LAVH: the mean difference was 137.00 € (95% CI 88.95-185.05 €; 294 women; 1 study).
  
  
  CONCLUSIONS
  At the present NOTES should be considered as a technique under evaluation for use in gynaecological surgery. RCTs are needed to demonstrate its effectiveness.
authors.affiliation: Department of Obstetrics and Gynaecology, Imelda Hospital, Imeldalaan 9, 2820, Bonheiden, Belgium.
authors.forename: Jan
authors.initials: J
authors.lastname: Baekelandt
authors.affiliation: Department of Anaesthesiology, Imelda Hospital, Imeldalaan 9, 2820, Bonheiden, Belgium.
authors.forename: Peter A
authors.initials: PA
authors.lastname: De Mulder
authors.affiliation: Department of Anaesthesiology, Imelda Hospital, Imeldalaan 9, 2820, Bonheiden, Belgium.
authors.forename: Ilse
authors.initials: I
authors.lastname: Le Roy
authors.affiliation: Clinical and Experimental Endocrinology, UZ Gasthuisberg, Herestraat 49-Box 902, 3000, Leuven, Belgium.
authors.forename: Chantal
authors.initials: C
authors.lastname: Mathieu
authors.affiliation: Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), Kapucijnenvoer 35 blok D-Box 7001, 3000, Leuven, Belgium.
authors.forename: Annouschka
authors.initials: A
authors.lastname: Laenen
authors.affiliation: Interfaculty Institute for Family and Sexuality Studies, Department of Neuroscience, KU Leuven, Kapucijnenvoer 7 blok G-Box 7001, 3000, Leuven, Belgium.
authors.forename: Paul
authors.initials: P
authors.lastname: Enzlin
authors.affiliation: Universitaire Vrouwenkliniek, University Hospital Gent, De Pintelaan 185, 9000 Gent, Belgium.
authors.forename: Steven
authors.initials: S
authors.lastname: Weyers
authors.affiliation: The Robinson Institute, School of Paediatrics and Reproductive Health, The University of Adelaide, 55 King William St., North Adelaide, SA 5006, Australia.
authors.forename: Ben W J
authors.initials: BW
authors.lastname: Mol
authors.affiliation: Department of Obstetrics and Gynaecology, Imelda Hospital, Imeldalaan 9, 2820, Bonheiden, Belgium; CEBAM, The Centre for Evidence-based Medicine, Cochrane Belgium, Academic Centre for General Practice, Kapucijnenvoer 33 blok J-Box 7001, 3000, Leuven, Belgium. Electronic address: jan.bosteels@med.kuleuven.be.
authors.forename: Jan J A
authors.initials: JJ
authors.lastname: Bosteels
mesh_terms: D000328:Adult; D016063:Blood Loss, Surgical / Q000517:prevention & control; D019317:Evidence-Based Medicine; D005260:Female; D005831:Genital Diseases, Female / Q000191:economics / Q000601:surgery*; D017722:Hospital Charges; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects* / Q000191:economics; D010535:Laparoscopy / Q000009:adverse effects / Q000191:economics; D007902:Length of Stay; D057605:Natural Orifice Endoscopic Surgery / Q000009:adverse effects* / Q000191:economics; D011183:Postoperative Complications / Q000191:economics / Q000209:etiology / Q000517:prevention & control* / Q000628:therapy; D019106:Postoperative Hemorrhage / Q000191:economics / Q000209:etiology / Q000517:prevention & control / Q000628:therapy; D011788:Quality of Life; D014591:Uterine Diseases / Q000191:economics / Q000601:surgery*
keywords: Comparative studies; Laparoscopic hysterectomy; Laparoscopy assisted hysterectomy; NOTES; Randomised controlled trials