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Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials

BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7506.1478 (Published 23 June 2005) Cite this as: BMJ 2005;330:1478
  1. Neil Johnson, associate professor (n.johnson{at}auckland.ac.nz)11,
  2. David Barlow, head of department2,
  3. Anne Lethaby, biostatistician1,
  4. Emma Tavender, collaborative review group coordinator3,
  5. Liz Curr, registrar in obstetrics and gynaecology1,
  6. Ray Garry, professor of obstetrics and gynaecology4
  1. 1 University of Auckland, National Women's Department of Obstetrics and Gynaecology, Auckland Hospital, Auckland, New Zealand
  2. 2 Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford OX3 9DU
  3. 3 Cochrane Oral Health Group, University of Manchester, Manchester
  4. 4 University of Western Australia Department of Obstetrics and Gynaecology, Perth, Australia
  1. Correspondence to: N Johnson
  • Accepted 9 May 2005

Abstract

Objective To evaluate the most appropriate surgical method of hysterectomy (abdominal, vaginal, or laparoscopic) for women with benign disease.

Design Systematic review and meta-analysis.

Data sources Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, and Biological Abstracts.

Selection of studies Only randomised controlled trials were selected; participants had to have benign gynaecological disease; interventions had to comprise at least one hysterectomy method compared with another; and trials had to report primary outcomes (time taken to return to normal activities, intraoperative visceral injury, and major long term complications) or secondary outcomes (operating time, other immediate complications of surgery, short term complications, and duration of hospital stay).

Results 27 trials (total of 3643 participants) were included. Return to normal activities was quicker after vaginal than after abdominal hysterectomy (weighted mean difference 9.5 (95% confidence interval 6.4 to 12.6) days) and after laparoscopic than after abdominal hysterectomy (difference 13.6 (11.8 to 15.4) days), but was not significantly different for laparoscopic versus vaginal hysterectomy (difference −1.1 (−4.2 to 2.1) days). There were more urinary tract injuries with laparoscopic than with abdominal hysterectomy (odds ratio 2.61 (95% confidence interval 1.22 to 5.60)), but no other intraoperative visceral injuries showed a significant difference between surgical approaches. Data were notably absent for many important long term patient outcome measures, where the analyses were underpowered to detect important differences, or they were simply not reported in trials.

Conclusions Significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it brings a higher chance of bladder or ureter injury.

Footnotes

  • Contributors NJ, DB, AL, and RG jointly conceived the idea for the study. NJ helped to design the study, wrote the protocol, helped to select trials for inclusion and do the data extraction, conducted the analyses, and wrote the final manuscript. He is also the guarantor for the paper. DB helped to design the study and commented on the protocol and the final manuscript. AL helped to design the study, commented on the protocol, helped with the selection of trials for inclusion, with data extraction, and with the analyses, and commented on the final manuscript. ET and LC helped with the selection of trials for inclusion, with data extraction, and with the analyses, and commented on the final manuscript. RG helped to design the study and commented on the protocol and the final manuscript.

  • Competing interests RG is the principal investigator in a United Kingdom based multicentre randomised trial comparing laparoscopic hysterectomy with both abdominal and vaginal hysterectomy.

  • Ethical approval Not needed.

  • Accepted 9 May 2005
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