Vaginal Hysterectomy

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The data extracted from each study included the author, publication year, type of study, number of patients, routes of hysterectomy VH, LAVH, TLH and unspecified LH , and outcomes complications, operating time, blood loss, intraoperative conversion, postoperative pain, length of hospital stay and length of recuperation. We first tried to extract numerical data from tables, text or figures. If these data were not reported numerically, we extracted data from graphs using digital ruler software. When summary data included only the median and range, data were transformed according to the methods described by Hozo et al.

We used tools for assessing quality and risk of bias from the Cochrane Handbook for Systematic Reviews of Interventions to evaluate the methodological quality of RCTs [ 10 ]. The following seven items were evaluated:. Pairs of independent reviewers assessed the methodological quality. Discrepancies were resolved by consensus of the whole team. A meta-analysis was conducted using Review Manager version 5. Random-effects models were used to calculate a pooled estimate of effect in the meta-analysis.

After excluding duplicate citations, potentially eligible citations were identified and examined in detail. TLH; and VH vs. Hence, the number of studies on VH was duplicated in each outcome. The risks of bias in the included studies are summarised in Fig. Two of the studies specified inclusion of hysterectomy for benign uterine diseases only, and 12 studies included benign uterine diseases and limit of uterine or myoma size.

Vaginal Hysterectomy with THUNDERBEAT Open Extended Jaw

Three studies included benign uterine diseases and possible VH. Seventeen trials reported incidences of perioperative complications [ 5 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ], which were classified by Dindo classification grade I to V [ 6 ]. Grade I complications were fever, vault hoematoma, urinary tract infection, vaginal bleeding, urinary retention and unspecified infections.

One patient in the VH group was treated with heparin because of deep vein thrombosis and experienced a spontaneous resolution. Grade III complications included those requiring surgical, endoscopic, or radiological intervention. There was one ureteral injury, seven bladder injuries and two reoperations in the VH group and eight bladder injuries, one vesicovaginal fistula, one ureterovaginal fistula, one reoperation and two pulmonary embolisms in the LH group. Secondary outcomes were operating time, blood loss, intraoperative conversion, postoperative pain, length of hospital stay and length of recuperation.

However, all studies except one favored VH [ 31 ]; thus, the risk of inconsistency for this outcome was not severe.

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Twelve studies assessed intraoperative conversion [ 14 , 17 , 18 , 19 , 21 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. There was no difference between the two groups on the day of surgery WMD 0. Eleven studies reported on the length of hospital stay [ 14 , 17 , 19 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. Three studies assessed the duration of recuperation [ 14 , 17 , 25 ]. Many studies have compared the surgical approach and complications according to the type of surgery to determine which method is best for the patient. The conclusion suggests that abdominal hysterectomy is inferior to VH and LH [ 32 ].

There were few randomized trials comparing VH and LH for postoperative complications, operative time, hospital stay, and recovery. The results of our meta-analysis showed no difference between the two groups for the overall rate of complications, including grade I, II and III complications of intraoperative blood loss, intraoperative conversion, length of hospital stay and length of recuperation after surgery. An important matter of concern about LH is a higher incidence of urinary tract injuries [ 33 ]. Our meta-analysis showed no significant difference in urinary tract injuries between VH and LH 10 of vs.

A recent study of women undergoing hysterectomy for benign indications reported that the incidence of urinary tract injuries was 4. One review article reported that the incidence of ureteral injury is estimated to be 0. In this meta-analysis, we found that the incidence of urinary tract injuries was 1. Hence, the incidence of ureteral injury was unlikely to be underreported in the included studies. During TLH, many surgeons use electrical laparoscopic instruments to cauterize the uterine artery and dissect the vesicouterine fold; the incidence of fistula formation might thus increase as a consequence of thermal injury [ 36 ].

A Cochrane review in concluded that VH appears to be superior to LH for benign indications, as VH is associated with a faster return to normal activities than LH according to a meta-analysis including two studies of patients [ 14 , 17 ], and there were no advantages of LH over VH, as the operation time was longer for LH and the incidence of urinary tract injuries was greater for TLH than for VH [ 32 ].


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LH to Cochrane review in , the operation time of VH was significantly faster than that of LH similarly but we found no difference between the two groups in the time to return to normal activities, incidence of urinary tract injury and length of hospital stay. The more postoperative pain in LAVH in our study might be caused by the pneumoperitoneum, the pain caused by traction of uterus and the abdominal incisions for the ports [ 24 ]. One study concluded that LH was the least cost-effective due to the expensive laparoscopic devices and long operation time [ 37 ].

The operation time of LH has shortened over the last couple decades. However, the cost of disposable laparoscopic devices is inevitably more expensive than that of the conventional surgical instruments used in VH. Gynaecologists around the world should focus on the effect of the rapid development of LH on the treatment of benign indications, especially VH training and skills among residents.

What do I need to know about a vaginal hysterectomy?

When deciding the route of hysterectomy, the preference and proficiency of the surgeon may be the most decisive factors. As a result, if LH is performed more often than VH, gynaecologists in the future will be unfamiliar with VH, leading to a more profound decrease in the implementation of VH. Despite evidence supporting benefits of VH, current statistics indicate VH is underutilised in treating benign gynaecologic conditions [ 4 ]. The decreased utilisation of VH is undesirable because VH is the least invasive approach, shorter operating time and less cost than other types of hysterectomy from an evidence-based viewpoint.

Main causes associated with decreased utilisation of VH include changes of resident training in surgical techniques due to the tremendous developments of laparoscopic skills and devices, changes of surgical skills in practice, attention to alternative hysterectomy techniques, and enormous propaganda effects of laparoscopic device companies. To increase the rate of VH as the primary approach in possible cases, teaching hospitals around the world should try to increase utilisation of VH on purpose for increasing familiarity with VH during resident training.

According to our review, if both procedures are technically feasible, VH exhibits advantages in the operating time, which can be one of the most important factors for reducing hospital cost. All of hysterectomy cannot be performed by VH, but all of hysterectomy should not be performed laparoscopically. The limitation of our study is that all included studies had a high risk of bias in blinding despite the RCT design. However, given that our primary outcome was the comparison of complication risk between the two groups, outcomes such as overall complications, grade 3 complications and risk of urinary tract injuries had moderate-quality evidence.

Additional large-scale, multicenter, long-term randomized trials including objective outcome assessment will be required to definitively establish the value of LH vs VH. The results of this study suggest that VH should be the treatment of benign gynecologic disease when both operative methods are available. Large randomized controlled trials should be performed to identify differences in VH and LH outcomes for operation time, postoperative pain, perioperative complications and cost.

All data generated or analysed during this study are included in this published article and its Additional file 1. Inpatient hysterectomy surveillance in the United States, — Am J Obstet Gynecol. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. A dynamic quality assessment tool for laparoscopic hysterectomy to measure surgical outcomes. Vaginal hysterectomy: past, present, and future. Int Urogynecol J. Laparoscopic vs vaginal hysterectomy for benign pathology.

The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg.

The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Ann Intern Med. Estimating the mean and variance from the median, range, and the size of a sample.

Green S, Higgins J. Cochrane handbook for systematic reviews of interventions. Version; GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol.

Backgrounds

GRADE guidelines: 1. GRADE guidelines: 2. Framing the question and deciding on important outcomes.

Hysterectomy - Nucleus Health

Three methods for hysterectomy: a randomised, prospective study of short term outcome. Vaginal hysterectomy for enlarged uteri, with or without laparoscopic assistance: randomized study. Obstet Gynecol.

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Recovery from vaginal hysterectomy compared with laparoscopy-assisted vaginal hysterectomy: a prospective, randomized, multicenter study. Acta Obstet Gynecol Scand. Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least g: a prospective randomized study. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy.