Surgical approaches to hysterectomy for benign gynaecological disease
Vaginal hysterectomy should be preferred over abdominal hysterectomy. Where this is not possible, laparoscopic hysterectomy should be used to avoid the need for the abdominal approach.
RHL Commentary by Datta S and Bruce D
Menorrhagia, frequently associated with fibroids, is commonly observed in women of reproductive age in both developed and developing countries. Menorrhagia/fibroids have both physical (pain and anaemia) and sexual health (through disruption of sexual relations) consequences, and are associated with significant costs to the health system.
Treatment of fibroids includes hysterectomy. Currently, there are three different techniques of surgical treatment of benign gynaecological disease – abdominal hysterectomy, vaginal hysterectomy and laparoscopic hysterectomy. The laparoscopic method can be utilized in three ways– laparoscopy- assisted vaginal hysterectomy, laparoscopic hysterectomy, and total laparoscopic hysterectomy, in which the vaginal vault is closed laparoscopically. This review (1) compares the effects of alternative surgical treatments for benign gynaecological disease.
2. Methods of the review
The review authors 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. They sought to include only randomized controlled trials comparing one surgical approach to hysterectomy with another. The inclusion and exclusion criteria, respectively, were women undergoing hysterectomy for benign disease (including uterine fibroids) and women with gynaecological cancer.
3. Results of the review
A total of 34 trials with over 4495 participants were included in the review. Of the commonly used techniques, compared with abdominal hysterectomy, vaginal hysterectomy was associated with a shorter hospital stay [mean difference (MD) 1.1 days, confidence interval (CI) 0.9–1.2 days], speedier return to normal activities (MD 9.5 days, CI 6.4–12.6 days), fewer unspecified infections or febrile episodes [odds ratio (OR) 0.42, 95% 0.21–0.83]. When compared with abdominal hysterectomy, laparoscopic hysterectomy was associated with lesser intraoperative blood loss (MD 45 cc ) and smaller drop in haemoglobin levels (MD 0.55 g/dl), shorter duration of hospital stay (MD 2.0 days, 95% CI 1.9– 2.2 days), quicker return to normal activities (MD 13.6 days, 95% CI 11.8–15.4 days), fewer infections (OR 2.41, 95% CI 1.21–4.82) and febrile episodes. However, operating time was longer (on average 11 minutes) and more urinary tract injuries (OR 2.41, 95% CI 1.21–4.82) were seen.
There was no evidence of benefits of laparoscopic hysterectomy in comparison with vaginal hysterectomy and the operating time was increased with laparoscopic hysterectomy. There was also no evidence of any benefit of the different types of laparoscopic hysterectomy, although operating time was increased for laparoscopic hysterectomy compared with laparoscopy- assisted vaginal hysterectomy.
Vaginal hysterectomy should be preferred over abdominal hysterectomy. Where this is not possible, laparoscopic hysterectomy should be used to avoid the need for the abdominal approach. However, the duration of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when uterine arteries are divided laparoscopically. It should be kept in mind that laparoscopic approaches require greater surgical expertise. There are conflicting data on which of the surgical methods is the shortest to perform. This aspect is partly likely to be related to the prior experience of the surgeons involved in the procedures. 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 quality of some of the studies included in the review was judged by the reviewers to be inadequate. The small number of studies and the small number of participants in these trials were a major limitation of the review.
4.1 Applicability of the results
Hysterectomy is an effective end treatment for common debilitating gynaecological problems such as persistent menorrhagia. The results of the Cochrane Review are applicable to under-resourced health-care settings, particularly in relation to vaginal hysterectomy versus abdominal hysterectomy. One limitation is the cost of treatment and equipment, limiting the use of laparoscopic hysterectomy. However, given that no benefits were found for laparoscopic hysterectomy versus the vaginal approach, the latter should be the method of choice.
4.2 Implementation of the intervention
To properly implement surgical treatment of benign gynaecological disease, an outpatient review must first be in place in order to identify and screen women suitable for surgical treatment. Required equipment for a treatment programme will include a theatre with surgical instruments and anaesthetic equipment, as well as dedicated staff. Procedures must be performed under general or spinal anaesthesia. A multidisciplinary approach may be helpful where possible in the pre-operative setting. As many women in developing countries go through life without having a gynaecology clinic appointment, population awareness should be increased to ensure patient compliance with treatment and recovery. Support from government health-care departments is required to fund awareness campaigns and to follow up women with pathological findings. Use of surgical treatment for benign gynaecological disease cannot be seen in isolation from other issues of cost and experience of surgeons, although this review focuses on surgical treatment only.
4.3 Implications for research
For some important outcomes, the analyses were underpowered to detect important differences, or they were simply not reported in trials. Data were notably absent for many long-term outcome measures as well on the surgery performed (subtotal versus total, oophorectomy, etc.). (See also Cochrane review on “Total versus subtotal hysterectomy for benign gynaecological conditions (2) and “Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women” (3). Further research is needed to define the role of the newer approaches to hysterectomy such as total laparoscopic hysterectomy. Furthermore, several intermediary requirements such as training for laparoscopic surgery all need further assessment as the evidence for the current recommendations is limited. Further work is also needed to compare the various subcategories of laparoscopic hysterectomy, the costs of each treatment modality and their cost–benefit ratio.
Sources of support: Not applicable
- Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2009;Issue 3. Art. No.: CD003677; DOI: 10.1002/14651858.CD003677.pub4.
- Lethaby A, Ivanova V, Johnson N. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database of Systematic Reviews 2006;Issue 2. Art. No.: CD004993; DOI: 10.1002/14651858.CD004993.pub2.
- Orozco LJ, Salazar A, Clarke J, Tristán M. Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women. Cochrane Database of Systematic Reviews 2008;Issue 3. Art. No.: CD005638; DOI: 10.1002/14651858.CD005638.pub2.
This document should be cited as: Datta S and Bruce D. Surgical approaches to hysterectomy for benign gynaecological disease : RHL commentary (last revised: 1 June 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.