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

I have welcomed the flurry of rapid responses to our systematic
review of randomised trials comparing surgical approaches to hysterectomy
(Hutchon 28 June 2005; Pedlow 29 June 2005; Entwhistle et al 29 June 2005;
Magos et al 7 July 2005) – it is pleasing to see that at least some of my
colleagues internationally do care about level 1 evidence that should be
of interest to every practicing gynaecologist!

David Hutchon highlights the increased incidence of urinary tract
injury accompanying laparoscopic hysterectomy compared to abdominal
hysterectomy. It is currently unclear whether this relates to poor
clinical judgement amongst surgeons performing laparoscopic
hysterectomies, as David suggests, is an inherent risk with laparoscopic
approaches to hysterectomy, or is simply a function of the learning curve.
Extensive case series by individual surgeons are accumulating and these
suggest the learning curve with laparoscopic hysterectomy and its
associated injuries may run into many hundreds of cases.

Peter Pedlow is to be congratulated – his personal odyssey of
progression to vaginal hysterectomy shows, in the face of many
institutions (including my own in Auckland) struggling to change their
majority of hysterectomies for benign disease being performed abdominally,
that with a commitment to vaginal hysterectomy, rates in excess of 70%
vaginal hysterectomy can be achieved for non-prolapse hysterectomy with
benign disease. Like Adam Magos et al, Peter promotes the concept of
ovarian surgery vaginally.

David and Adam may wish to consider one another’s diametrically
opposed arguments. At one pole, David advances an increasingly popular
argument amongst surgeons committed to laparoscopic approaches, extolling
the virtues of “such a safe procedure as diagnostic laparoscopy” being a
useful adjunct that in his hands “makes vaginal hysterectomy more likely
to be completed safely”. At the opposite pole, Adam remains an ardent
vaginal oophorectomist. These expressed views, neither of which are
supported nor refuted by the best available randomized trial evidence in
our review, demonstrate that individuals’ prior beliefs (dare I say
biases, or is this more to do with personal experience and expertise with
vaginal and laparoscopic surgery?) strongly colour how we interpret
available evidence. Furthermore these differences of opinion highlight the
challenges facing us when we systematically review randomised trials of
surgical interventions using methodology better suited to comparisons of
medical interventions. How generalisable are such results and how are they
squared with individual surgeons’ expertise with various surgical
approaches? Drug A versus drug B will inevitably have little of the
clinical and statistical heterogeneity we have seen in the systematic
review of surgical approaches to hysterectomy, meaning that, even though
we had 27 randomised trials in our review, it still suffers to some extent
from limited generalisability. Adam’s group and others have had extensive
vaginal surgical experience and high success rates with removing ovaries
vaginally. Even in expert hands, however, there is an appreciable
percentage of ovaries that cannot be safely removed vaginally. Surgeons
surely need to operate within the limits of their expertise and many find
oophorectomy difficult with the vaginal approach. Why struggle with a
difficult oophorectomy vaginally when laparoscopic hysterectomy as an
adjunct to vaginal hysterectomy is a procedure with a low complication
rate. Frankly, I agree with Adam that “the need for oophorectomy should
not be considered a contra-indication to vaginal hysterectomy”, but may I
underscore heavily the statement that “a laparoscopic approach may be
appropriate if an oophorectomy is needed” (or if surgeons like David wish
to view Caesarean adhesions, or other pelvic pathology such as fibroids,
with the option of dealing with the pathology laparoscopically or
vaginally). An RCT comparing BSO vaginally versus laparoscopically in
conjunction with a vaginal hysterectomy is the only way to know for sure,
but the sample size would need to be powered carefully.

The data of Vikki Entwhistle et al concerning women’s views on the
surgical approach to their own hysterectomy are extremely powerful. They
re-emphasise the imperative of clear communication of the rationale
underpinning the choice of surgical approach to hysterectomy with our
patients. Vikki is outlining what is surely inevitable – that we need to
explain the benefits and hazards of the various approaches and encourage
women to be involved in the decision of the surgical approach to their
hysterectomy.

And what about all this talk of ENT surgeons and dentists? They, like
us, are gradually realising that many of the structures they have removed,
happily through the mouth and not the side of the neck, maybe didn’t need
to be removed at all. Should we remove the tongue through the cheek or
not? Maybe just leave it in there!

Competing interests:
None declared