Vaginal rather than abdominal hysterectomy should be performed “whenever technically feasible” to reduce potential complications and to speed hospital discharge and patients' return to normal activities, according to a new review of randomized controlled trials that have compared hysterectomy techniques.
“The many advantages demonstrated from avoiding abdominal hysterectomy … suggest that [it] should be avoided if it is possible and safe to do so,” wrote Neil Johnson, M.D., of the University of Auckland in New Zealand, and his colleagues.
The investigators also concluded that when vaginal hysterectomy is not possible, laparoscopic hysterectomy has advantages over abdominal hysterectomy, including a speedier recovery.
These advantages can be “offset,” however, by longer operating times and more urinary tract injuries, the investigators said.
The “systematic evidence review” of surgical approach to hysterectomy for benign gynecologic disease was conducted by the Cochrane Collaboration, an international organization that evaluates medical research and draws evidence-based conclusions about medical practice.
Leading experts in the United States predicted that—no matter how significant and informative—the conclusions of the metaanalysis will likely fall flat at home, particularly as they concern the issue of vaginal versus abdominal hysterectomy.
Physicians' choice of approach for hysterectomy is so tightly tied with experience and with physicians' “comfort” level that the predominance of the abdominal approach in the United States is unlikely to change, they said.
“I don't think there's ever been an economic incentive for one route over another. It's a training and comfort issue,” said Thomas Stovall, M.D., president of the Society of Gynecologic Surgeons. “I think we'll continue to see [choices] based on practice patterns and training.”
According to a 2002 report on hysterectomy issued by the Centers for Disease Control and Prevention—the most recent surveillance conducted—more than 60% of hysterectomies performed in the United States between 1994 and 1999 were abdominal. “I don't think the figures are that much different today,” Dr. Stovall said.
The Cochrane investigators searched Medline and numerous other registries and reviewed data from 27 randomized controlled trials that compared hysterectomy approaches in almost 3,650 women, the majority of whom were 41-50 years of age.
All but 7 of the trials were single-center trials (including two from the United States), and the majority of the 27 trials compared various types of laparoscopic surgery with either vaginal or abdominal hysterectomy. Three trials compared all three approaches, and two trials (published in 2002 and 2003) compared vaginal with abdominal hysterectomy.
The investigators found that, compared with abdominal surgery, vaginal hysterectomy meant a shorter stay in the hospital (by approximately 1 day), a quicker return to normal activities (10 vs. 13 days), and fewer infections and febrile episodes (odds ratio 0.42).
Laparoscopic hysterectomy (various types of laparoscopic surgery were pooled together) also had advantages over abdominal hysterectomy: less intraoperative blood loss, a smaller drop in hemoglobin level, a similarly shorter hospital stay and quicker return to normal activity, fewer wound or abdominal wall infections, and fewer unspecified infections or febrile episodes.
Laparoscopic operations were more likely than abdominal hysterectomies to result in urinary tract injuries, however (OR 2.61). And in general, they were longer operations (14 vs. 11 minutes). (The exception was laparoscopically assisted vaginal hysterectomy without uterine artery ligation; these operations were significantly shorter than abdominal hysterectomy.)
When compared with traditional vaginal hysterectomy, laparoscopic approaches fell short in the metaanalysis, leaving unanswered the question of whether laparoscopic procedures should be performed when vaginal hysterectomies are achievable, the investigators said (Cochrane Database Syst. Rev. 2005 [1]:CD003677.DOI:10.1002/14651858. CD003677.pub2).
There were no apparent benefits of laparoscopic hysterectomy over the vaginal approach; the speed of patient recovery and other issues were similar, and there was no statistically significant difference in the rate of urinary tract injuries. Laparoscopic procedures took longer (49 vs. 42 minutes), however.
The introduction of laparoscopic techniques into gynecologic training has been beneficial in that it has increased “surgeons' confidence and skill with vaginal surgery, thus making vaginal hysterectomy a more feasible option for many,” they said.
Such a happening has yet to play out in the United States, however, said Alan Johns, M.D., past president of the Society of Reproductive Surgeons and the American Association of Gynecologic Laparoscopists.
“The skill level of the gynecologic surgeon has actually dropped dramatically,” said Dr. Johns, who practices in Fort Worth, Tex. “The average graduate has not done enough vaginal hysterectomy … and laparoscopic skills are not taught in the vast majority of residency programs.” Patients also don't demand alternatives to traditional abdominal surgery, he said.
According to the 2002 CDC study, rates of laparoscopically assisted vaginal hysterectomies more than doubled between 1994 and 1999, from 13% of all vaginal hysterectomies to 28%. The overall rate of vaginal hysterectomy remained stable, however.