The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy

OBJECTIVE

To compare the effects of laparoscopic hysterectomy and abdominal hysterectomy in the abdominal trial, and laparoscopic hysterectomy and vaginal hysterectomy in the vaginal trial.

DESIGN

Two parallel, multicentre, randomised trials.

SETTING

28 UK centres and two South African centres.

PARTICIPANTS

1380 women were recruited; 1346 had surgery; 937 were followed up at one year. Primary outcome Rate of major complications.

RESULTS

In the abdominal trial laparoscopic hysterectomy was associated with a higher rate of major complications than abdominal hysterectomy (11.1% v 6.2%, P = 0.02; difference 4.9%, 95% confidence interval 0.9% to 9.1%) and the number needed to treat to harm was 20. Laparoscopic hysterectomy also took longer to perform (84 minutes v 50 minutes) but was less painful (visual analogue scale 3.51 v 3.88, P = 0.01) and resulted in a shorter stay in hospital after the operation (3 days v 4 days). Six weeks after the operation, laparoscopic hysterectomy was associated with less pain and better quality of life than abdominal hysterectomy (SF-12, body image scale, and sexual activity questionnaires). In the vaginal trial we found no evidence of a difference in major complication rates between laparoscopic hysterectomy and vaginal hysterectomy (9.8% v 9.5%, P = 0.92; difference 0.3%, -5.2% to 5.8%), and the number needed to treat to harm was 333. We found no evidence of other differences between laparoscopic hysterectomy and vaginal hysterectomy except that laparoscopic hysterectomy took longer to perform (72 minutes v 39 minutes) and was associated with a higher rate of detecting unexpected pathology (16.4% v 4.8%, P = < 0.01). However, this trial was underpowered.

CONCLUSIONS

Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy. It also took longer to perform but was associated with less pain, quicker recovery, and better short term quality of life. The trial comparing vaginal hysterectomy with laparoscopic hysterectomy was underpowered and is inconclusive on the rate of major complications; however, vaginal hysterectomy took less time.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions depending on the part of the procedure performed laparoscopically.

OBJECTIVES

To assess the most beneficial and least harmful surgical approach to hysterectomy for women with benign gynaecological conditions.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (15 August 2008), CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), EMBASE (1980 to August 2008), Biological Abstracts (1969 to August 2008), the National Research Register, and relevant citation lists.

SELECTION CRITERIA

Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included.

DATA COLLECTION AND ANALYSIS

Independent selection of trials and data extraction were employed following Cochrane guidelines.

MAIN RESULTS

There were 34 included studies with 4495 women. The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections (odds ratio (OR) 0.42), and shorter duration of hospital stay (MD 1.1 days). The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections (OR 0.31) at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection (OR 3.77) and shorter operation time (MD 25.3 minutes). There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding (OR 2.76) were increased in LH. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials. Data were absent for many important long-term outcome measures.

AUTHORS' CONCLUSIONS

Because of equal or significantly better outcomes on all parameters, VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH however the length of the surgery increases as the extent of the surgery performed laparoscopically increases. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH).

OBJECTIVES

To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions.

SEARCH METHODS

We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

MAIN RESULTS

We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies.

AUTHORS' CONCLUSIONS

Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.

Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy?

OBJECTIVE

The aim of this study was to investigate the feasibility and safety of laparoscopic management of obese women with early stage endometrial cancer and to compare the surgical outcome, cost, hospital stay, recall of postoperative pain control, time to return to full activity and to work, and overall satisfaction among these women and those managed by laparotomy.

METHODS

We conducted a prospective study over 2 years applying laparoscopic surgery to all women with clinical stage I endometrial cancer and body mass indices (BMIs) between 28.0 and 60.0 who can tolerate such surgery. As a control, we used women with clinical stage I endometrial cancer and similar BMIs who underwent laparotomy in the previous 2 years. Both groups were compared in their characteristics, surgical outcome, cost, and hospital stay, and interviewed regarding time to recovery, recall of postoperative pain control, and overall satisfaction with their management.

RESULTS

Forty of 42 obese women who presented with clinical stage I endometrial cancer during the study period were offered laparoscopic surgery. The procedure was converted to laparotomy in 3 (7.5%) patients. Laparoscopic surgery was thus successful in 88.1% of all obese women. There was no significant difference between women who underwent laparoscopy and those who underwent laparotomy in patient characteristics, proportion of women who underwent lymphadenectomy, complications, total cost, patients' recall of postoperative pain, and patients' satisfaction with management. Women who underwent laparoscopy had a significantly longer operative time, more pelvic lymph nodes removed, a smaller drop in postoperative hematocrit, less pain medication, and a shorter hospital stay (194.8 versus 137.7 min, P <0.001; 11.3 versus 5.3, P < 0.001; 3.9 versus 5.4, P = 0.029; 32.3 versus 124.1 mg, P < 0.001; and 2.5 versus 5.6 days, P < 0.001, respectively). There was a trend toward earlier resumption of full activity and return to work among women who underwent laparoscopy (23.2 versus 45.0 days, P = 0.073, and 35.3 versus 67.0 days, P = 0.055, respectively).

CONCLUSIONS

Most obese women with early stage endometrial cancer can be safely managed through laparoscopy with excellent surgical outcome, shorter hospitalization, and less postoperative pain than those managed through laparotomy.

Surgical management of pelvic organ prolapse in women: a short version Cochrane review

BACKGROUND

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse.

OBJECTIVES

To determine the effects of the many different surgeries in the management of pelvic organ prolapse.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.

DATA COLLECTION AND ANALYSIS

Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding.

MAIN RESULTS

Twenty two randomised controlled trials were identified evaluating 2368 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated.

AUTHORS' CONCLUSIONS

Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed.

Laparoscopic-assisted vaginal versus abdominal surgery in patients with endometrial cancer--a prospective randomized trial

OBJECTIVE

We compared a laparoscopic-vaginal approach with the conventional abdominal approach for treatment of patients with endometrial cancer.

METHOD

Between July 1995 and August 1999, 70 patients with endometrial cancer FIGO stage I-III were randomized to laparoscopic-assisted simple or radical vaginal hysterectomy or simple or radical abdominal hysterectomy with or without lymph node dissection.

RESULTS

Thirty-seven patients were treated in the laparoscopic versus 33 patients in the laparotomy group. Lymph node dissection was performed in 25 patients by laparoscopy and in 24 patients by laparotomy. Blood loss and transfusion rates were significantly lower in the laparoscopic group. Yield of pelvic and para-aortic lymph nodes, duration of surgery, and incidence of postoperative complications were similar for both groups. Overall and recurrence-free survival did not differ significantly for both groups.

CONCLUSION

The laparoscopic-vaginal approach for treatment of endometrial cancer is associated with lower perioperative morbidity compared with the conventional abdominal approach.

Laparoscopic-assisted vaginal hysterectomy for endometrial cancer: clinical outcomes and hospital charges

OBJECTIVE

Our objective was to compare the clinical outcomes and associated hospital charges between two methods of hysterectomy for patients with early-stage endometrial cancer.

METHODS

Retrospective chart review of 320 patients with early-stage endometrial cancer treated by laparoscopic-assisted vaginal hysterectomy (LAVH) or total abdominal hysterectomy (TAH) was performed for the period of July 1, 1991, to September 30, 1996, at Memorial Sloan-Kettering Cancer Center.

RESULTS

Sixty-nine patients (22%) were treated by LAVH, and 251 (78%) were treated by TAH. The majority of the patients (80%) had Stage I disease. The mean age was similar for both groups: 60 years for the LAVH vs 61 years for TAH. The mean weight was significantly lower for the LAVH group, 71 kg (range 43-117 kg), than for the TAH group, 82 kg (range 38-200 kg), (P < 0.05). Overall complication rates were lower among patients treated by LAVH. Operating room time was longer for the LAVH group (214 min) than for the TAH group (144 min) (P < 0.05). The median length of stay was significantly shorter for patients treated by LAVH (2.0 days) compared to TAH (6.0 days) (P < 0.05). Room charges were significantly higher for the TAH patients ($6960) compared to the LAVH patients ($3130) (P < 0.05). Overall mean total charges were significantly less for the LAVH group ($11,826) than for the TAH group ($15,189) (P < 0.05). With a median follow-up of 30 months for the TAH group and 18 months for the LAVH group, there was no significant difference in disease recurrence (P = 0.91).

CONCLUSION

Patients treated by LAVH for early-stage endometrial cancer had significantly shorter hospitalization and fewer complications, resulting in less overall hospital charges when compared to patients treated by TAH. Long-term outcome was similar. Laparoscopic-assisted vaginal hysterectomy is an attractive alternative for selected patients with early-stage endometrial cancer.

Costs and charges associated with three alternative techniques of hysterectomy

BACKGROUND

Many hysterectomies are now performed by a laparoscopically assisted vaginal technique. This procedure is controversial, partly because of concern about cost. We studied hospital charges and costs for the procedure as compared with those for total abdominal hysterectomy and total vaginal hysterectomy in clinically similar groups of patients.

METHODS

From hospital-discharge data and patients' charts, we identified hysterectomies performed in 1993 and 1994 by 96 surgeons at a community teaching hospital to treat benign conditions. The patients were grouped according to the surgical procedures performed in conjunction with the hysterectomy. Data on hospital charges and cost-to-charge ratios for 64 hospital cost centers were used to assess charges and costs for specific resources, as well as for the hospitalization overall.

RESULTS

Of 1049 patients studied, 26 percent underwent laparoscopically assisted vaginal hysterectomy, 54 percent underwent abdominal hysterectomy, and 20 percent underwent vaginal hysterectomy. The average hospital stays were 2.6, 3.9, and 2.9 days, respectively, and the mean total charges (facility charges plus professional fees) for the hospitalizations were $6,116, $5,084, and $4,221 (P<0.001 for the comparison of the laparoscopic technique with both other techniques). The mean facility costs were $4,914, $3,954, and $3,116, respectively (P<0.001 for the same comparison), with similar findings in all subgroups. The higher charges and costs for laparoscopically assisted vaginal hysterectomy were due to higher supply costs, particularly when disposable supplies were used, and to longer operating-room time.

CONCLUSIONS

Despite shorter hospital stays, in-hospital charges and costs for laparoscopically assisted vaginal hysterectomy are higher than for either alternative procedure, because of the disposable supplies that are typically used and the longer operating-room time.

Guidelines to determine the route of hysterectomy

OBJECTIVE

To 1) test the validity of a method of assigning patients prospectively to a vaginal, abdominal, or laparoscopy-assisted vaginal approach to hysterectomy for benign disease; 2) compare the outcomes of these options from the day of surgery to the first day of returning to normal activities; and 3) estimate the proportion of hysterectomies by each route when patients were assigned according to this system, and the impact on hospital charges.

METHODS

Six hundred seventeen women were assigned to a route of hysterectomy on the basis of uterine size (greater or less than 280 g), presumptive risk factors, and uterine or adnexal immobility or inaccessibility. Data regarding the success of the procedure, complications, length of hospital stay and convalescence, and hospital charges were compiled.

RESULTS

Vaginal hysterectomy alone (n = 548) or in conjunction with laparoscopy (n = 63) was successful in 99.5% of women assigned to these groups. Patients in whom the vaginal route was successful included 94% of those with uterine weights exceeding 280 g and 97% of those having risk factors often cited as reasons for selecting abdominal hysterectomy. Laparoscopic surgery was necessary to permit a transvaginal operation in only 12 of 63 patients (19%). Use of the guidelines produced a potential savings of 615 hospital days, $1,317,434 in hospital charges, and 7250 convalescent days relative to the 3:1 ratio of abdominal to vaginal hysterectomies prevalent in the United States.

CONCLUSIONS

Specific guidelines for uterine size, risk factors, and uterine and adnexal mobility and accessibility are useful in selecting the operative approach to hysterectomy and will significantly reduce the number of abdominal operations performed. Laparoscopy is valuable in properly selected patients to determine the route of hysterectomy, but the need for laparoscopic techniques to permit a vaginal operation may be considerably less than some investigators have proposed.

Oncological safety of laparoscopic-assisted vaginal radical trachelectomy (LARVT or Dargent’s operation): A comparative study with laparoscopic-assisted vaginal radical hysterectomy (LARVH)

OBJECTIVE

The aim of our study was to compare the results of radical trachelectomy (LARVT or Dargent's operation) to radical vaginal hysterectomy (LARVH) in terms of intraoperative and postoperative morbidity and mainly in terms of risk of tumor recurrence. Each technique is associated with laparoscopic pelvic lymph node dissection. Our objective was to know if performing radical trachelectomy in order to preserve the fertility of a young patient with an early cervical cancer is associated or not with an increased risk of operative morbidity or tumor recurrence.

METHODS

Patient affected by early invasive cervical cancer who has been submitted to LARVT (n=118) in our Institute between December 1986 and December 2003 has been compared to patients treated by LARVH (n=139) in the same period. All patient's information, surgical and pathological data and oncological results have been prospectively collected. The associations between the discrete variables were assessed using chi(2) test with Yate's correction when appropriate. Fisher's exact test was used when it was necessary. Continuous variables were compared by Student's t test. p values less than 0.05 were considered statistically significant. Statistical analysis used the Kaplan-Meier method to calculate disease-free and overall survival.

RESULTS

Between December 1986 and December 2003, 118 and 139 patients have undergone LARVT and LARVH, respectively, for FIGO stage I-IIA carcinoma of the cervix. The two populations (LARVT and LARVH) are comparable in terms of the main prognostic factors of cervical cancer. The rate of intraoperative complications has been similar in the two groups (2.5% for LAVRT and 5.8% for LAVRH, p=NS). Also the rate of postoperative complications has been similar in the two groups (21.2% for LAVRT and 19.4% for LAVRH, p=NS). When considering the risk of recurrence, the results in the two groups are also identical: 7 cases (5.2%) in patients treated with LAVRT and 9 cases (8.5%) in patients treated with LAVRH (p=NS).

CONCLUSION

Our data demonstrate that early cervical cancer (less than 2 cm diameter) can be treated successfully with LARVT with similar efficacy and recurrence rates to LARVH. In our experience radical trachelectomy is a safe treatment for young women affected by early cervical cancer who want to conserve their fertility.

Identification and preservation of the motoric innervation of the bladder in radical hysterectomy type III

OBJECTIVE

To decrease postoperative morbidity associated with radical hysterectomy Rutledge type III, we identified the parasympathetic innervation of the bladder in the cardinal ligament.

METHODS

During laparoscopic dissection of the cardinal ligament, we used 7x magnification on 38 consecutive patients with cervical cancer stages IB1 to IIIA with high risk for parametrial involvement when we performed laparoscopy-assisted radical vaginal hysterectomy type III between August 1997 and January 1999.

RESULTS

The middle rectal artery was identified as a landmark separating the vascular from the neural part of the cardinal ligament. The neural part was shown to contain the splanchnic pelvic nerves which anastomose with the pelvic plexus. Following preservation of these neural structures all patients were able to void their bladder spontaneously. Following nerve-sparing technique, patients regained bladder function significantly quicker compared with a control group (n = 28) in which the neural part of the cardinal ligament had not been preserved: suprapubic drainage 11.2 days versus 21.4 days (P = 0.0007).

CONCLUSION

Using the middle rectal artery as a landmark the neural part of the cardinal ligament can be preserved, resulting in preservation of the motor function of the bladder.

A comparison of laparascopic-assisted radical vaginal hysterectomy and radical abdominal hysterectomy in the treatment of cervical cancer

OBJECTIVES

The aim of this study was to compare peri-operative morbidity and recurrence-free survival of early-stage cervical cancer patients treated by laparoscopic-assisted radical vaginal hysterectomy (LARVH) with time-matched radical abdominal hysterectomy (RAH) controls at our center.

METHODS

Since July 1984, all patients with FIGO stage IA/IB cervical cancer undergoing radical surgery by members of our division have been entered into a prospective database. Since November 1996, one surgeon at our center has performed LARVH on all surgically appropriate patients. Non-parametric tests were used. Differences between medians were compared using Wilcoxon Rank Sum test. Statistical analysis used the Kaplan-Meier method to calculate disease-free survival. Differences between survival curves were compared with the log rank test. Statistical significance was defined as P < 0.05.

RESULTS

Between November 1996 and December 2003, 71 and 205 patients have undergone LARVH and RAH, respectively, for FIGO stage IA/IB carcinoma of the cervix. Both groups were similar with respect to age and Quetelet index. There were no differences in tumor size, histology, grade, depth of invasion, lymph node metastases, or surgical margins. All laparoscopic procedures were completed successfully with no conversions to laparotomy. Intra-operative morbidity characteristics analyzed (LARVH vs. RAH) were blood loss 300 ml vs. 500 ml (P < 0.001), operative time 3.5 h vs. 2.5 h (P < 0.001), and intra-operative complications 13% vs. 4% (P < 0.03). Intra-operative complications in the LARVH group included: cystotomy (7), ureteric injury (1), and bowel injury (1). There was no difference in transfusion rates. There was no difference between post-operative infectious and non-infectious complications (LARVH vs. RAH), 9% vs. 5% and 5% vs. 2%, respectively. The median time to normal urine residual was 10 days vs. 5 days (P < 0.001), and the median length of hospital stay was 1 day vs. 5 days (P < 0.001). Twenty-two percent of patients received post-operative radiotherapy for high-risk features in both groups. After a median follow-up of 17 and 21 months, there have been 4 recurrences in the LARVH group and 13 in the RAH (P = NS). The overall 2-year recurrence-free survival was 94% and 94% in the LARVH and RAH groups, respectively (P = NS).

CONCLUSION

Our data demonstrate that early cervical cancer can be treated successfully with LARVH with similar efficacy and recurrence rates to RAH. The major benefits are less intra-operative blood loss and shorter hospital stay. It is a safe procedure with low overall morbidity and complication rates. However, at present, LARVH is associated with an increase in intra-operative complications, and patients may have an increased time to return to normal bladder function.

A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy

OBJECTIVE

To identify differences in the peri-operative outcome of women undergoing hysterectomy with bilateral salpingo-oophorectomy performed either by abdominal hysterectomy and bilateral salpingo-oophorectomy or by laparoscopic-assisted salpingo-oophorectomy and vaginal hysterectomy. To identify any potential management implications, including financial differences, between these two forms of operations.

SUBJECTS AND METHODS

Eighty women undergoing hysterectomy and bilateral salpingo-oophorectomy for benign gynaecological conditions were prospectively randomised to have the procedure by laparoscopic-assisted bilateral salpingo-oophorectomy and vaginal hysterectomy or total abdominal hysterectomy and bilateral salpingo-oophorectomy. The peri-operative and post-operative courses of both groups were compared.

RESULTS

Although laparoscopic-assisted bilateral salpingo-oophorectomy and vaginal hysterectomy took longer (100 (SD 5.6) versus 57 (SD 4.7) min, P < 0.0001), the women undergoing this procedure had a shorter time in hospital (3.5 versus six days, P < 0.0001) quicker recovery (three versus six weeks, P < 0.0001) and returned to work earlier. There were minimal complications in both groups and they were not significantly different. The cost of the laparoscopic-assisted procedure was greater during the operation with longer operating time and cost of disposable instruments. However, the total cost of treatment was less in this group because of shortened post-operative stay.

CONCLUSION

The study shows laparoscopic-assisted bilateral salpingo-oophorectomy and vaginal hysterectomy is a safe and cost-effective procedure for women requiring a hysterectomy and bilateral salpingo-oophorectomy.

Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study

OBJECTIVE

The objective of this study was to evaluate short-term results of laparoscopically assisted vaginal hysterectomy with those of total abdominal hysterectomy in a prospective, randomized, multicenter study.

STUDY DESIGN

One hundred sixteen patients referred for abdominal hysterectomy were randomized to either laparoscopically assisted vaginal hysterectomy (58 patients) or abdominal hysterectomy (58 patients). Inclusion criteria were one or more of the following, where a vaginal hysterectomy would be traditionally contraindicated: uterine size larger than 280 g, previous pelvic surgery, history of pelvic inflammatory disease, moderate or severe endometriosis, concomitant adnexal masses or indication for adnexectomy, and nulliparity with lack of uterine descent and limited vaginal access. An upper limit of uterine size was set at 16 weeks' gestation (ie, 700 g).

RESULTS

There were no differences in terms of patient's age, parity, preoperative hemoglobin levels, mean uterine weight, and total operating time between the 2 groups. Estimated blood losses and postoperative day 1 hemoglobin drop were significantly lower for laparoscopically assisted vaginal hysterectomy than for abdominal hysterectomy (P<.05). There were 1 major and 2 minor complications in the laparoscopically assisted vaginal hysterectomy group compared with 2 major and 5 minor complications in the abdominal hysterectomy group (P not significant). Postoperative pain was lower for laparoscopically assisted vaginal hysterectomy than for abdominal hysterectomy on postoperative days 1, 2, and 3 (P<.05). Postoperative hospital stay was significantly shorter for laparoscopically assisted vaginal hysterectomy than for abdominal hysterectomy (P<.001).

CONCLUSIONS

The present study demonstrates that, given adequate training in laparoscopic surgery, laparoscopically assisted vaginal hysterectomy may replace abdominal hysterectomy in most patients who require a hysterectomy and have contraindications to vaginal hysterectomy, with all the benefits associated with the vaginal route.

Combined laparoscopic and vaginal surgery for the management of two cases of stage I endometrial cancer

Two postmenopausal patients with stage I adenocarcinoma of the endometrium who were managed with a combined laparoscopic and vaginal approach are presented. Surgical-pathologic staging was performed laparoscopically, with exploration of the abdomen and procurement of peritoneal cytology and pelvic and para-aortic lymph nodes. The adnexa were ligated and mobilized laparoscopically and removed with the vaginal hysterectomy. This approach offers decreased morbidity to the patient yet still obtains the same pathologic information and surgical goal as the traditional transabdominal approach.

Laparoscopy as the primary modality for the treatment of women with endometrial carcinoma

BACKGROUND

The current study was conducted to assess the feasibility of laparoscopy in the treatment of women with early stage endometrial carcinoma and to compare the surgical outcome, cost, and quality of life among these patients with those treated with laparotomy.

METHODS

A prospective study was conducted over 2 years in which all women with early stage endometrial carcinoma who could tolerate laparoscopic surgery were treated with laparoscopically assisted vaginal hysterectomy (LAVH), bilateral salpingo-oophorectomy (BSO), and lymphadenectomy. Women with a similar disease stage who underwent similar surgical procedures through laparotomy in the previous 2 years were used as the control group. Both groups were compared with regard to their characteristics, surgical outcome, and cost and were interviewed regarding their quality of life.

RESULTS

Eighty-six of 90 women with endometrial carcinoma underwent LAVH. The procedure was converted to laparotomy in 5 patients (5.8%). Laparoscopic surgery thus was successful in 90% of the women. There were no significant differences noted between those women who underwent LAVH and those who underwent total abdominal hysterectomy (TAH) (n = 57) with regard to patient characteristics, type of surgical procedure, preoperative and postoperative hematocrit, complications, patient recall of postoperative pain, and tumor recurrence. LAVH patients had significantly smaller body mass indices, a longer surgical time, more pelvic lymph nodes, a smaller decrease in postoperative hematocrit, received less pain medication, had a shorter hospital stay, an earlier return to full activity and work, and a higher level of satisfaction with their treatment, although their procedures had a higher cost compared with TAH patients.

CONCLUSIONS

The majority of women with early stage endometrial carcinoma can be treated with laparoscopy with an excellent surgical outcome, shorter hospitalization, earlier recovery, and improved quality of life, but with a higher financial cost.

Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele

OBJECTIVE

This study compared 3 surgical methods of prophylaxis against enterocele formation employed at the time of vaginal hysterectomy.

STUDY DESIGN

One hundred consecutive women undergoing total vaginal hysterectomy for various reasons were randomly assigned to have 1 of 3 surgical methods applied to the posterior superior aspect of the vagina for prophylaxis against enterocele formation. The first procedure involved closing the cul-de-sac and bringing the uterosacral-cardinal complex together in the midline in a vaginal Moschcowitz-type operation. The second procedure was a McCall-type culdeplasty to obliterate the cul-de-sac, plicate the uterosacral-cardinal complex, and elevate any redundant posterior vaginal apex. The third technique used only the peritoneum to close the cul-de-sac, allowing passive movement of the uterosacral-cardinal complex to the midline, no obliteration per se, and no elevation of the posterior vagina. Postoperative findings on pelvic examination were evaluated at 6 weeks, 3 months, and 1, 2, and 3 years. Statistical analysis was performed with the chi2 test of independence.

RESULTS

At 6 weeks' follow-up and at 3 months' follow-up there were no prolapses involving the posterior superior segment of the vagina. At 1 year of follow-up 11 patients had stage 1 or 2 posterior superior segment prolapse. At 2 years' follow-up this number was 16. At 3 years' follow-up the McCall-type method was statistically better (chi2 = 11.27 with 2 degrees of freedom, P =. 004) than the other 2 in preventing postoperative enterocele (n = 2 of 32 with McCall-type procedure, n = 10 of 33 with vaginal Moschcowitz-type procedure, and n = 13 of 33 with peritoneal closure only).

CONCLUSION

When applied at the time of vaginal hysterectomy the McCall-type culdeplasty is superior to a vaginal Moschcowitz-type procedure and to simple peritoneal closure in preventing subsequent enterocele.

Three methods for hysterectomy: a randomised, prospective study of short term outcome

OBJECTIVE

To detect differences in clinical short term outcome between total abdominal hysterectomy, vaginal hysterectomy and laparoscopic assisted vaginal hysterectomy.

DESIGN

Randomised controlled trial.

SETTING

Department of Obstetrics and Gynaecology, Hospital of Helsingborg, Sweden.

SAMPLE

One hundred-twenty women scheduled for hysterectomy for various indications.

METHODS

Randomisation into three treatment arms: total abdominal hysterectomy (n = 40); vaginal hysterectomy (n = 40) and laparoscopic assisted vaginal hysterectomy (n = 40). During traditional abdominal and vaginal surgery, laparoscopic assistance was kept to a minimum. Substantial number of cases needed volume-reducing manoeuvres due to uterine size.

MAIN OUTCOME MEASURES

Duration of surgery, anaesthesia, time in hospital and recovery time.

RESULTS

Mean duration (range) of surgery was significantly longer for laparoscopic assisted vaginal hysterectomy compared with vaginal hysterectomy and total abdominal hysterectomy, 102 min (50-175), 81 min (35-135) and 68 min (28-125), respectively. Mean stay in hospital and mean time to recovery was significantly longer for total abdominal hysterectomy compared with vaginal hysterectomy and laparoscopic assisted vaginal hysterectomy. The difference between vaginal hysterectomy and laparoscopic assisted vaginal hysterectomy was not significant. It was possible to remove uteri under 600 g with all three methods. Four laparoscopic assisted vaginal hysterectomies and one vaginal hysterectomy were converted to open surgery. Reoperation and blood transfusion were required after two vaginal hysterectomies and one laparoscopic assisted vaginal hysterectomy. One woman needed blood transfusion after total abdominal hysterectomy.

CONCLUSIONS

Traditional vaginal hysterectomy proved to be feasible and the faster operative technique compared with vaginal hysterectomy with laparoscopic assistance. The abdominal technique was somewhat faster, but time spent in theatre was not significantly shorter. Abdominal hysterectomy required on average a longer hospital stay of one day and one additional week of convalescence compared with traditional vaginal hysterectomy. Vaginal hysterectomy should be a primary method for uterine removal.

Vaginal hysterectomy for the large uterus

OBJECTIVE

To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size.

DESIGN

A prospective observational study.

SETTING

The Royal Free Hospital, London.

PARTICIPANTS

Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size.

INTERVENTIONS

Vaginal hysterectomy with or without bilateral salpingo-oophorectomy or oophorectomy.

MAIN OUTCOME MEASURES

Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra- and post-operative complications, duration of hospitalisation.

RESULTS

The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (n = 6) and superficial vaginal grazes (n = 5). One of the women required a blood transfusion. The mean post-operative hospital stay was 3.7 days (range 2 to 9 days).

CONCLUSION

Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.

Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy

OBJECTIVE

We compared operative time, length of hospital stay, postoperative recovery, return to work, and costs for women undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy.

STUDY DESIGN

A prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy (n = 24) versus abdominal hysterectomy (n = 24) was carried out in a tertiary care setting. The main outcome variables were operative time, length of hospital stay, and return to work. Secondary outcomes were postoperative pain and return to normal activity as determined by weekly visual analog scales and daily diary. Hospital costs were calculated.

RESULTS

The laparoscopically assisted vaginal hysterectomy group had longer operative times (median and quartiles, laparoscopically assisted vaginal hysterectomy 180 [139, 225] minutes vs abdominal hysterectomy 130 [97, 155] minutes), lower requirements for postoperative intravenous analgesia (patient-controlled analgesia pump, median and quartiles: laparoscopically assisted vaginal hysterectomy 22.1 [15.9, 23.5] hours, abdominal hysterectomy 36.7 [26.2, 45.0] hours), shorter length of hospital stay (median and quartiles, laparoscopically assisted vaginal hysterectomy 1.5 [1.0, 2.3] days, abdominal hysterectomy 2.5 [1.5, 2.5] days), and quicker return to work (Kaplan-Meier analysis, P =.03). Both procedures had similar hospital costs (P =.21).

CONCLUSION

Laparoscopically assisted vaginal hysterectomy appears to allow patients a more rapid postoperative recovery and an earlier return to work with hospital costs similar to those of abdominal hysterectomy.

A randomised controlled trial comparing abdominal and vaginal prolapse surgery: effects on urogenital function

OBJECTIVE

To compare the effects of vaginal hysterectomy (combined with anterior and/or posterior colporraphy) and abdominal sacro-colpopexy (with preservation of the uterus) on urogenital function.

DESIGN

Randomised trial.

SETTING

Three teaching hospitals in The Netherlands.

POPULATION

Eighty-two patients undergoing surgical correction of uterine prolapse stages II-IV.

METHODS

Participating patients completed the urogenital distress inventory (UDI), before and at six weeks, six months and one year after surgery, to measure discomfort of prolapse and micturition symptoms. Domain scores of the UDI (ranging from 0 to 100, higher scores indicating more discomfort) were compared between groups at all time points. Findings at pelvic examination, number of doctor visits within the first year after surgery because of pelvic floor symptoms and performed or planned surgery of recurrent genital prolapse were also compared.

MAIN OUTCOME MEASURE

Domain scores of the UDI at one year after surgery.

RESULTS

At one year after surgery, scores on the discomfort/pain domain (mean difference 7.1, 95% confidence interval [CI] 1.1-13.2), overactive bladder domain (mean difference 8.7, 95% CI 0.5-16.9) and obstructive micturition domain (mean difference 10.3, 95% CI 0.6-20.1) of the UDI were significantly higher in the abdominal group than in the vaginal group. Findings at pelvic examination were similar in both groups. Doctor visits because of pelvic floor symptoms were more frequent in the abdominal group than in the vaginal group. Re-operation was performed or planned in 9 of the 41 patients who underwent abdominal surgery and in 1 of the 41 patients who underwent vaginal surgery (odds ratio [OR] = 11.2, 95% CI 1.4-90.0).

CONCLUSIONS

Our findings suggest that vaginal hysterectomy with anterior and/or posterior colporraphy is preferable to abdominal sacro-colpopexy with preservation of the uterus as surgical correction in patients with uterine prolapse stages II-IV.

Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse

OBJECTIVE

Our purpose was to compare anatomic and functional results of 2 procedures performed at vaginal hysterectomy for vaginal vault suspension in patients with advanced uterovaginal prolapse.

STUDY DESIGN

A retrospective case-control study was designed comparing 62 patients who underwent sacrospinous ligament fixation and 62 members of a matched control group who underwent modified McCall culdoplasty during vaginal hysterectomy and reconstructive pelvic surgery. The 62 pairs were matched for grade of uterine prolapse, age, parity, dystocia, menopause, body mass index, previous prolapse surgery, heavy work, constipation, and chronic cough.

RESULTS

Operative time and blood loss were significantly greater (P < .001) in the group with sacrospinous suspension. With a follow-up from 4 to 9 years, 17 (27%) patients receiving sacrospinous suspension had prolapse recurrence at any vaginal site compared with 9 (15%) patients receiving modified McCall culdoplasty (P = .14). Recurrent vault prolapse was recorded in 5 (8%) and 3 (5%) subjects, respectively (P = .72). Thirteen (21%) and 4 (6%) patients, respectively, had recurrent cystocele (matched odds ratio 4.1, 95% confidence interval 1.3 to 14.2, P = .04). No significative difference was observed in postoperative sexual function.

CONCLUSION

Sacrospinous ligament fixation is not recommended as a prophylactic measure at vaginal hysterectomy in patients with uterovaginal prolapse.

Clinical significance of lympho vascular space involvement and lymph node micrometastases in early-stage cervical cancer: A retrospective case-control surgico-pathological study

OBJECTIVE

Several studies have shown that lympho vascular space involvement (LVSI) and lymph node micrometastases (LNmM) may be risk factors for recurrence in early-stage cervical cancer with no apparent lymph node metastases. We performed a retrospective case-control study to reassess whether the presence of lymph node micrometastases and LVSI is predictive of subsequent recurrence following surgical resection of early-stage cervical cancer.

METHODS

In a series of 292 patients diagnosed with early cervical cancer and treated by the same surgical procedure (laparoscopic-vaginal radical hysterectomy) during the same time period, two paired series were selected. The first series consisted of 26 cases who recurred in a median time of 36.8 months and the second series were 26 cases matched for age, histological sub-type, surgico-pathological stage and maximal tumor diameter, who did not recur after a median follow-up of 122 months. Sections taken from the hysterectomy specimens were reassessed for LVSI. All the lymph node blocks which have initially been considered as uninvolved were submitted to serial sectioning. Immunohistochemical staining using anti-cytokeratins AE1 and AE3 was used for identifying LNmM.

RESULTS

LVSI was twice more frequent and LNmM ten-fold more frequent in the group of patients who recurred: 20/26 (77%) versus 9/26 (35%) and 11/26 (42%) versus 1/26 (4%) respectively. The relative risk of recurrence is 2.64 (1.67-5.49, P < 0.01) in the presence of LVSI and 2.44 (1.58-3.78, P < 0.01) in the presence of LNmM. All the patients with LNmM were LVSI positive. At bivariate analysis, the true LNmM (deposits more than 200 um in size) was the only independent risk factor.

CONCLUSIONS

LNmM is an important risk factor of tumor recurrence in patients with early cervical cancer with no apparent lymph node metastases. LNmM seems to occur only in LVSI positive tumors. These data may lead to improve management of early-stage cervical cancer to reduce the risk of recurrence in those cases.

Surgical routes and complications of hysterectomy for benign disorders: a prospective observational study in French university hospitals

BACKGROUND

Despite the advantages of the vaginal and laparoscopic approaches, most hysterectomies carried out involve laparotomy. The objective of this prospective observational multicentre study was to examine the routes and complications of hysterectomy for benign disorders.

METHODS

Of the 15 university hospitals belonging to Collégiale de Gynécologie-Obstétrique de Paris-Ile de France, 12 participated in this study that took place between June and December 2004. We analysed the characteristics of the patients, the indications for hysterectomy and intra- and post-operative complications (and their determinants) according to the surgical approach.

RESULTS

In total, 634 women underwent hysterectomy for benign disorders during the study period. The patients' mean age (+/-SD), BMI, parity and previous Caesarean sections were 51.4 +/- 10.3 years, 25 +/- 5.7 kg/m(2), 2 +/- 1.6 children and 0.2 +/- 0.6, respectively. Hysterectomy was performed by the laparoscopic, laparoscopically assisted vaginal hysterectomy (LAVH), laparotomic and vaginal routes in 19.1, 8.2, 24.4 and 48.3% of cases, respectively. The operating time was shorter with the vaginal route than with laparoscopy, laparotomy and LAVH (P < 0.0001). Intra- and post-operative complications were significantly more frequent in the laparotomic group (18%) compared with the vaginal group (8.2%), the laparoscopic group (5.8%) and the LAVH group (8.2%) (P < 0.0001). In a multivariate logistic regression model, obesity [odds ratio (OR): 2.84, 95% confidence interval (CI): 1.53-5.27, P = 0.001], history of pelvic surgery (OR: 2.47, 95% CI: 1.39-4.39, P = 0.002) and history of Caesarean section (OR: 2.04, 95% CI: 1.01-4.1, P = 0.046) were significantly associated with intra- and post-operative complications. Laparoconversion was necessary in 36 cases (7.5%) overall and was more frequent with laparoscopy and LAVH than with the vaginal route (P < 0.0001).

CONCLUSIONS

This study confirms that the vaginal route is increasingly used for hysterectomy in France and that it is the route of choice for benign disorders.