Research
General gynecology
Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials

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Objective

Recent randomized trials comparing total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH) have produced conflicting results. The role of TLH in women suitable for VH remains uncertain.

Study Design

This study was a metaanalysis of randomized studies comparing TLH and VH for benign disease. Pooled outcome measures (odds ratio [OR] and weighted mean difference [WMD]) were calculated using random-effects models.

Results

No differences in perioperative complications, either total (pooled odds ratio, 0.87; P = .74) or by grade of severity, were demonstrated. TLH was associated with reduced postoperative pain scores (WMD −2.1; P = .03) and reduced hospital stay (WMD −0.62 days; P < .0001) but took longer to perform (WMD 29.3 minutes; P = .003). No differences in blood loss, rate of conversion to laparotomy, or urinary tract injury were identified.

Conclusion

TLH may offer benefits compared with VH for benign disease, although this analysis is likely underpowered for rare complications. Further studies of long-term outcomes, including prolapse, urinary incontinence, and sexual function, are required.

Section snippets

Search strategy

This metaanalysis was prepared in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.13 PubMed, Medline, SCOPUS, and Cochrane Databases were searched in June 2010 for combinations of the terms “laparoscopic,” “hysterectomy,” “vaginal,” “outcome,” “randomiz(s)ed,” and “benign.” The primary search was performed individually by 2 authors (R.G. and C.A.W.) for relevant trials published between January 1989 (the year that LH was

Results

The primary search retrieved 269 abstracts, which were screened for eligible studies. Thirty-one potentially eligible citations were identified and examined in detail (Figure 1). Of these, 19 were not RCTs and were excluded. Of the remaining 12 studies, 7 studies described “laparoscopically assisted hysterectomy,” which did not meet a strict definition of TLH. The other 5 papers reported results from RCTs comparing VH with TLH and were included in the present analysis.10, 11, 12, 19, 20 Four

Inclusion/Exclusion Criteria of Studies

Table 3 details the inclusion and exclusion criteria for the 5 studies included in this metaanalysis. Three of the studies specified inclusion of hysterectomy for benign disease only and another included only benign and premalignant indications. One study19 recruited women in whom total hysterectomy was indicated, without reference to benign disease per se. In general, exclusion criteria were consistent across studies. Four of the included trials excluded women with pelvic organ prolapse (POP)

Primary Outcome

All 5 trials reported incidence of perioperative complications. The study by Morelli et al20 reported incidence of both fever and hematoma (not requiring transfusion or drainage). Because the likelihood of crossover between these groups was high, we included only results for fever (the more common complication) to prevent duplication. Overall, no differences in the rate of any complication were found between VH (89 of 331) and TLH (113 of 332; pooled OR, 0.87; 95% confidence interval [CI],

Secondary Outcomes

Secondary outcomes were operating time, blood loss, urinary tract injury, rate of conversion to laparotomy, postoperative pain, and length of postoperative stay.

Comment

In contemporary gynecological practice, it is recommended that, where possible, hysterectomy for benign indications should be approached vaginally.5 Previous studies have not shown laparoscopic hysterectomy to confer benefit compared with VH.6, 21 However, many of these studies are older and as the experience of TLH among gynecologists has grown, the superiority of VH over laparoscopic hysterectomy, particularly TLH, has begun to be challenged.9 Several retrospective studies have already

Conclusions

A number of recent studies have compared the perioperative outcomes of TLH and VH for benign indications. Our metaanlaysis suggests that both approaches have a comparable incidence of Dindo grades I, II, and III complications. Surgical approach did not influence rates of blood loss or urinary tract injury, although this analysis may be underpowered to detect differences in rare complications. TLH was associated with both reduced postoperative pain and reduced length of postoperative hospital

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    Cite this article as: Gendy R, Walsh CA, Walsh SR, et al. Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2011;204:388.e1-8.

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