ResearchGeneral gynecologyVaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials
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
References (30)
- et al.
Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial
Am J Obstet Gynecol
(2002) - et al.
Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis
Eur J Obstet Gynecol Reprod Biol
(2009) - et al.
A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease
Eur J Obstet Gynecol Reprod Biol
(2010) - et al.
The AAGL classification system for laparoscopic hysterectomyClassification committee of the American Association of Gynecologic Laparoscopists
J Am Assoc Gynecol Laparosc
(2000) - et al.
Assessing the quality of reports of randomized clinical trials: is blinding necessary?
Control Clin Trials
(1996) - et al.
Meta-analysis in clinical trials
Control Clin Trials
(1986) - et al.
A randomized study of total abdominal, vaginal and laparoscopic hysterectomy
Int J Gynaecol Obstet
(2003) - et al.
Total laparoscopic versus vaginal hysterectomy: a retrospective comparison
J Obstet Gynaecol Can
(2008) - et al.
The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases
J Am Assoc Gynecol Laparosc
(2002) - et al.
Trends in inpatient prolapse procedures in the United States, 1979-2006
Am J Obstet Gynecol
(2010)
Inpatient hysterectomy surveillance in the United States, 2000-2004
Am J Obstet Gynecol
Hysterectomy rates in the United States, 2003
Obstet Gynecol
Total laparoscopic hysterectomy: indications, techniques and outcomes
Curr Opin Obstet Gynecol
Hysterectomy for benign disease
Obstet Gynecol
Surgical approach to hysterectomy for benign gynaecological disease
Cochrane Database Syst Rev
Cited by (0)
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.