title: Comparison of Vaginal Hysterectomy Techniques and Interventions for Benign Indications: A Systematic Review.
abstract: To create evidence-based clinical practice guidelines based on a systematic review of published literature regarding the risks and benefits of available preoperative, intraoperative, and postoperative technical steps and interventions at the time of vaginal hysterectomy for benign indications.
  
  
  
  We systematically searched the literature to identify studies that compared technical steps or interventions during the preoperative, intraoperative, and postoperative periods surrounding vaginal hysterectomy. We searched MEDLINE, Cochrane Central Register of Controlled Trials, Health Technology Assessments, and ClinicalTrials.gov from their inception until April 10, 2016, using the MeSH term "Hysterectomy, Vaginal" and associated text words. We included comparative studies, single-group studies, and systematic reviews published in English.
  
  
  
  We double-screened 4,250 abstracts, identifying 60 eligible studies. Discrepancies were adjudicated by a third reviewer. We followed standard systematic review methodology and the Grades for Recommendation, Assessment, Development and Evaluation approach to evaluate the evidence and generate guideline recommendations.
  
  
  
  Because of limited literature, only 16 perioperative risks, technical steps, and interventions were identified: obesity, large uteri, prior surgery, gonadotropin-releasing hormone agonists, vaginal antisepsis, bilateral salpingo-oophorectomy, morcellation, apical closure, uterine sealers, hemostatic injectants, hot cone, retractor, cystoscopy, vaginal packing, bladder management, and accustimulation. We organized and reported these as four domains: patient selection, preoperative, intraoperative, and postoperative. We did not identify any patient characteristics precluding a vaginal approach; chlorhexidine or povidone is appropriate for vaginal antisepsis; vasopressin decreases blood loss by 130 cc; tissue-sealing devices decrease blood loss by 44 cc and operative time by 15 minutes with uncertain complication implications; vertical cuff closure results in 1-cm increased vaginal length; either peritoneum or epithelium can be used for colpotomy closure; and routine vaginal packing is not advised.
  
  
  
  Minimal data exist to guide surgeons with respect to planning and performing a vaginal hysterectomy. This study identifies available information and future areas for investigation.
authors.affiliation: University of New Mexico, Albuquerque, New Mexico; the University of Texas Southwestern Medical Center, Dallas, Texas; Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; the University of North Carolina, Chapel Hill, North Carolina; the University of Alabama at Birmingham, Birmingham, Alabama; ProHealth, Waukesha Memorial Hospital, Waukesha, Wisconsin; Columbia University Medical Center and Icahn School of Medicine at Mount Sinai, New York, New York; the Center for Evidence Based Medicine, Brown University School of Public Health, Providence, Rhode Island; and the Institute for Female Pelvic Medicine and Reconstructive Surgery, North Wales, Pennsylvania.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Jeppson
authors.forename: Sunil
authors.initials: S
authors.lastname: Balgobin
authors.forename: David D
authors.initials: DD
authors.lastname: Rahn
authors.forename: Kristen A
authors.initials: KA
authors.lastname: Matteson
authors.forename: Alexis A
authors.initials: AA
authors.lastname: Dieter
authors.forename: David R
authors.initials: DR
authors.lastname: Ellington
authors.forename: Sarit O
authors.initials: SO
authors.lastname: Aschkenazi
authors.forename: Cara
authors.initials: C
authors.lastname: Grimes
authors.forename: Mamta M
authors.initials: MM
authors.lastname: Mamik
authors.forename: Ethan M
authors.initials: EM
authors.lastname: Balk
authors.forename: Miles
authors.initials: M
authors.lastname: Murphy
mesh_terms: D005260:Female; D006801:Humans; D007045:Hysterectomy, Vaginal / Q000009:adverse effects*; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D016032:Randomized Controlled Trials as Topic; D014591:Uterine Diseases / Q000601:surgery*; D016387:Women's Health