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

doi:10.1136/bmj.330.7506.1478

BMJ 2005;330:1478 (25 June), doi:10.1136/bmj.330.7506.1478

Paper

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

Neil Johnson, associate professor¹, David Barlow, head of department², Anne Lethaby, biostatistician¹, Emma Tavender, collaborative review group coordinator³, Liz Curr, registrar in obstetrics and gynaecology¹, Ray Garry, professor of obstetrics and gynaecology⁴

¹ University of Auckland, National Women's Department of Obstetrics and Gynaecology, Auckland Hospital, Auckland, New Zealand, ² Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford OX3 9DU, ³ Cochrane Oral Health Group, University of Manchester, Manchester, ⁴ University of Western Australia Department of Obstetrics and Gynaecology, Perth, Australia

Correspondence to: N Johnson n.johnson{at}auckland.ac.nz

Objective To evaluate the most appropriate surgical method ofhysterectomy (abdominal, vaginal, or laparoscopic) for womenwith benign disease.

Design Systematic review and meta-analysis.

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

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

Results 27 trials (total of 3643 participants) were included.Return to normal activities was quicker after vaginal than afterabdominal hysterectomy (weighted mean difference 9.5 (95% confidenceinterval 6.4 to 12.6) days) and after laparoscopic than afterabdominal hysterectomy (difference 13.6 (11.8 to 15.4) days),but was not significantly different for laparoscopic versusvaginal hysterectomy (difference -1.1 (-4.2 to 2.1) days). Therewere more urinary tract injuries with laparoscopic than withabdominal hysterectomy (odds ratio 2.61 (95% confidence interval1.22 to 5.60)), but no other intraoperative visceral injuriesshowed a significant difference between surgical approaches.Data were notably absent for many important long term patientoutcome measures, where the analyses were underpowered to detectimportant differences, or they were simply not reported in trials.

Conclusions Significantly speedier return to normal activitiesand other improved secondary outcomes (shorter duration of hospitalstay and fewer unspecified infections or febrile episodes) suggestthat vaginal hysterectomy is preferable to abdominal hysterectomywhere 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.

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Rapid Responses:

Read all Rapid Responses

More specialised gynaecological surgeons needed: David J R Hutchon
bmj.com, 28 Jun 2005 [Full text]
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Methods of hysterectomy: should women have a say?: Vikki A Entwistle, et al.
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Interesting Perspectives on Level 1 Evidence for Surgical Approach to Hysterectomy: Neil P Johnson
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Re: Oophorectomy at vaginal hysterectomy ?: Adam Magos
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Methods of hysterectomy and ureteric injury.: Roger A. McMaster-Fay
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Surgical Approach to Hysterectomy and Ureteric Injury: Neil P Johnson
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