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Laparoscopic vs vaginal hysterectomy for benign pathology

Published:January 12, 2009DOI:https://doi.org/10.1016/j.ajog.2008.09.016

      Objective

      The objective of the study was to compare length of stay, blood loss, operative time, and pain of laparoscopic and vaginal hysterectomy.

      Study Design

      This was a prospective, randomized, controlled comparison between vaginal (VH) and laparoscopic (LH) hysterectomy among 60 consecutive patients with a uterine volume of 300 mL or less and without uterine prolapse. Patients were followed up for 12 months.

      Results

      The groups were significantly different for mean operative time (VH: 81 ± 30 minutes; LH: 99 ± 25 minutes; P = .033) and blood loss (LH: 83 ± 57 mL; VH: 178 ± 149 mL; P = .004). Bilateral adnexectomy was performed when preoperatively planned in 73% of cases of the vaginal arm, whereas it was always performed in the laparoscopic arm (P = .045). Postoperative pain on day 0 and the number of days of analgesic request were higher in the vaginal group (P = .023 and P = .017, respectively). LH was associated with a reduced hospital stay (LH: 2.7 ± 0.5 days; VH: 3.2 ± 0.6 days; P < .001).There were no differences between the groups at the follow-up.

      Conclusion

      Laparoscopic hysterectomy results in a shorter hospital stay, less blood loss, and less postoperative pain compared with vaginal hysterectomy.

      Key words

      After cesarean section, hysterectomy is the second most frequent gynecological operation:
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      Hysterectomy surveillance—United States, 1980-1993.
      in France it is performed in 60,000 women per year;
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      Hysterectomies for benign disorders.
      in the United States, almost 30-40% of women younger than 65 years have undergone a hysterectomy;
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      • Xia Z.
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      Hysterectomy in the United States, 1988-1990.
      • Ryan M.M.
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      and in Italy, the rate of this operation for patients between 40 and 70 years old is 15%.
      • Van Keep P.A.
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      Hysterectomy in six European countries.
      See Journal Club, page 465
      Traditionally, about 70-80% of hysterectomies have been performed by laparotomy.
      • Wilcox L.S.
      • Koonin L.M.
      • Pokaras R.
      • Strauss L.T.
      • Xia Z.
      • Peterson H.B.
      Hysterectomy in the United States, 1988-1990.
      • Gimbel H.
      • Zobbe V.
      • Andersen B.M.
      • Filtenborg T.
      • Gluud C.
      • Tabor A.
      Randomised controlled trial of total compared with subtotal hysterectomy with one year follow up results.
      In the last 10 years, however, several published studies demonstrated that laparotomic hysterectomy, compared with both vaginal and laparoscopic hysterectomy, has a higher incidence of complications, a longer hospital stay, and longer convalescence.
      • Kovac S.R.
      Guidelines to determine the route of hysterectomy.
      • Summitt Jr, R.L.
      • Stovall T.G.
      • Steege J.F.
      • Lipscomb G.H.
      A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates.
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      • et al.
      Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States The collaborative review of sterilization.
      As a consequence, in Western countries, a reduction of 38% of laparotomic hysterectomy was observed, with an increase of laparoscopic and vaginal operations.
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      Hysterectomy of benign indications in Denmark 1988-1998 A register based trend analysis.
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      Hysterectomy trends in Finland in 1987-1995 A register-based analysis.
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      Supracervical and total abdominal hysterectomy trends in New York State: 1990-1996.
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      Has endometrial ablation replaced hysterectomy for the treatment of uterine bleeding? National figures.
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      Clinical indications for hysterectomy route: patient characteristics or physician preference?.
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      Vaginal removal of the benign nonprolapsed uterus: experience with 300 consecutive operations.
      • Sheth S.S.
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      Vaginal hysterectomy following previous caesarean section.
      • Magos A.
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      • Sinha R.
      • Richardson R.E.
      • O'Connor H.
      Vaginal hysterectomy for the large uterus.
      • Agostini A.
      • Bretelle F.
      • Cravello L.
      • Maisonneuve A.S.
      • Roger V.
      • Blanc B.
      Vaginal hysterectomy in nulliparous women without prolapse: a prospective comparative study.
      • Doucette R.C.
      • Sharp H.T.
      • Alder S.C.
      Challenging generally accepted contraindications to vaginal hysterectomy.
      • Unger J.B.
      Vaginal hysterectomy for women with a moderate enlarged uterus weighing 200 to 700 grams.
      • Darai E.
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      • Laplace C.
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      Vaginal hysterectomy for enlarged uteri, with or without laparoscopic assistance: randomized study.
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      • Kunde D.
      Vaginal route as the norm when planning hysterectomy for benign conditions: change in practice.
      • Unger J.B.
      • Meeks G.R.
      Vaginal hysterectomy in women with history of previous caesarean delivery.
      • Lambaudie E.
      • Occelli B.
      • Boukerrou M.
      • Crepin G.
      • Cosson M.
      Vaginal hysterectomy in nulliparous women: indications and limits.
      • Boukerrou M.
      • Lambaudie E.
      • Collinet P.
      • Crepin G.
      • Cosson M.
      Previous cesarean section is an operative risk factor in vaginal hysterectomy.
      There is a paucity of studies, however, that compare vaginal and laparoscopic hysterectomy, but it is still in debate which of these approaches is preferred in case of benign pathology.
      • Garry R.
      • Fountain J.
      • Mason S.
      • et al.
      The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy.
      • Hwang J.L.
      • Seow K.M.
      • Tsai Y.L.
      • Huang L.W.
      • Hsieh B.C.
      • Lee C.
      Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomy for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomised study.
      • Long C.Y.
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      • Chen W.C.
      • Su J.H.
      • Hsu S.C.
      Comparison of total laparoscopic hysterectomy and laparoscopically assisted vaginal hysterectomy.
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      • Ottosen L.
      Three methods for hysterectomy: a randomised prospective study of short term outcome.
      • Perino A.
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      • Castelli A.
      • Cittadini E.
      Total laparoscopical hysterectomy: an assessment of the learning curve in a prospective randomised study.
      • Richardson R.E.
      • Bournas N.
      • Magos A.L.
      Is laparoscopic hysterectomy a waste of time?.
      • Ribiero S.C.
      • Ribiero R.M.
      • Santos S.C.
      • Pinotti J.A.
      A randomised study of total abdominal, vaginal and laparoscopic hysterectomy.
      • Soriano D.
      • Goldstein A.
      • Lecuru F.
      • Darai E.
      Recovery from vaginal hysterectomy compared with laparoscopically assisted hysterectomy: a prospective, randomised, multicenter study.
      • Summitt Jr, R.L.
      • Stoval T.G.
      • Limpscomb G.H.
      • Ling F.W.
      Randomized comparison of laparoscopically assisted vaginal hysterectomy with vaginal standard hysterectomy in an outpatient setting.
      The aim of the present study was to compare, in a prospective randomized study, the intra- and postoperative outcome of vaginal and laparoscopic hysterectomy, both performed according to standardized techniques, with a 12-month follow-up. The main outcome was to evaluate whether there could be a difference in terms of earlier discharge between the 2 approaches.

      Materials and Methods

      From April 2004 to April 2006, patients referred to the Department of Gynecology and Obstetrics at San Paolo Hospital, University School of Medicine (Milan, Italy), with an indication to vaginal hysterectomy for benign pathology were invited to participate in a randomized trial to compare vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH).
      Exclusion criteria were a uterine volume greater than 300 mL, previous surgery for pelvic inflammatory disease or endometriosis, suspicion of malignancy, the presence of an ovarian cyst greater than 4 cm, and a vaginal prolapse higher than first degree. All the patients underwent a preoperative ultrasound scan, and the uterine volume was estimated according to the ellipsoid formula: longitudinal diameter (apart from cervix) × transverse diameter × anteroposterior diameter × 0.523. The study protocol was approved by the local institutional review board, and all participating patients gave their consent.
      All the procedures were performed by 2 skilled surgeons for each group. To minimize the potential confusing effect of the learning curve, only surgeons who had performed at least 50 procedures were involved. The vaginal hysterectomy was performed following Heaney's technique.
      • Heaney N.S.
      Vaginal hysterectomy: its indications and technique.
      The laparoscopic technique was always a total laparoscopic hysterectomy (IV E in the American Association of Gynecologic Laparoscopists [AAGL] classification.
      • Olive D.L.
      • Parker W.H.
      • Cooper J.M.
      • Levine R.L.
      The AAGL classification system for laparoscopic hysterectomy Classification committee of the American Association of Gynecologic Laparoscopists.
      • Candiani M.
      • DeMarinis S.
      Isterectomia laparoscopica.
      The AAGL classification describes the portion of the procedure completed under laparoscopic direction, with 4 types of hysterectomies (types I-IV) arranged according to increasing laparoscopic intervention. Type IV hysterectomy correspond to the complete detachment of cardinal-uterosacral ligament complex. “E” reflects the removal of the entire uterus, the laparoscopic closure of the vaginal cuff and its suspension to the uterosacral ligaments. We used the Clermont-Ferrand uterine manipulator for this type of hysterectomy.
      For each patient we recorded anamnestic data, including age; parity; previous surgery; body mass index (BMI); age of menopause or last period; the association of adnexal pathology and the indication to hysterectomy; intraoperative parameters including complications, blood loss, conversion to laparotomy, time of surgery, execution of adnexectomy (if preoperatively planned), correspondence to the ultrasound analysis, additional pelvic pathologies found during the surgery; and postoperative parameters including hospital stay, fever (temperature > 38°C), reduction of hemoglobin at day 1, restarting of bowel activity, infections, urinary dysfunctions, and pelvic pain. Foley's vesical catheter was maintained until the morning of the first day after surgery.
      To evaluate postoperative pain, we used the visual analog scale (VAS) score on days 0, 1, 2, and 3 after surgery; the number of analgesic tablets and vials requested by the patients was also recorded. Prophylactic antibiotic was given to all patients at the beginning of the surgery and repeated 12 h later.
      During the follow-up at months 1, 6, and 12, we made a clinical and ultrasound evaluation of the patients; we asked for pelvic pain, urinary and bowel dysfunctions, sexual problems, and satisfaction of the patients. We also used a questionnaire,
      • Kovac S.R.
      Guidelines to determine the route of hysterectomy.
      filled in at home, and delivered during the visits to assess these latest parameters.
      The primary endpoint of the trial was the hospital stay. We always used the same parameters to discharge patients: restarted bowel motility, regular abdomen and vaginal objectivity, absence of temperature (< 37°C), lack of urinary problems, and patient comfort. The secondary goals included pain, measured by a VAS, analgesic requests, blood loss, and execution of adnexectomy if preoperatively planned.
      The sample size was calculated based on the assumption that the expected discharge at day 2 was less than 5% in the vaginal arm and more than 30% in the laparoscopic arm. Based on these assumptions and setting the type I and II errors to the usual levels of 0.05 and 0.20, respectively, the number of cases to be treated per arm was about 30.
      Patients were randomized by means of a computer-generated list into 2 groups. Sealed opaque envelopes containing treatment allocation were opened after inclusion. Patients and physicians were not blinded to the treatment allocation.
      The data were analyzed on an SPSS statistical analysis package (SPSS Inc, Chicago, IL), using the Student's t-test for comparison of continuous data, and the χ2 analyses, including the Fischer's exact test, for nominal data. A value of P < .05 was accepted as significant.

      Results

      Sixty patients were recruited; 30 underwent VH and 30 underwent LH. The Figure describes the flow of the patients through the trial. All the participants were analyzed for primary and secondary outcomes. Baseline characteristics of the patients and indications to surgery were comparable (Table 1).
      Figure thumbnail gr1
      FIGUREFlow of participants throughout the study
      Candiani. Laparoscopic vs vaginal hysterectomy for benign pathology. Am J Obstet Gynecol 2009.
      TABLE 1Baseline characteristics and indications to surgery
      Baseline characteristicsLaparoscopyVaginalP value
      Age (y) ± SD48.96 ± 8.951.26 ± 8.8.364
      Menopause, n9 (30%)9 (30%)1.000
      Nulliparity, n10 (33%)3 (10%).087
      Previous cesarean section, n4 (13.3%)3 (10%).664
      Previous pelvic surgery, n18 (60%)16 (53.3%).569
      BMI ± SD24.4 ± 4.227.2 ± 6.3.057
      Mean uterine volume (mL) ± SD173 ± 72.5166 ± 66.2.729
      Indications to surgery, n.204
       Myomas15 (50%)22 (73.3%)
       Adenomyosis7 (23.3%)3 (10%)
       Endometrial hyperplasia5 (16.6%)5 (16.6%)
       Ovarian cysts3 (10%)0 (0%)
      Planned surgery, n1.000
       Hysterectomy13 (43.3%)12 (40%)
       H + monolateral adnexectomy2 (6.7%)2 (6.7%)
       H + bilateral adnexectomy15 (50%)16 (52.3%)
      BMI, body mass index; H, hysterectomy.
      Data are expressed as number (percentage), mean ± SD.
      Candiani. Laparoscopic vs vaginal hysterectomy for benign pathology. Am J Obstet Gynecol 2009.
      LH was associated with a longer mean operative time (VH: 82 ± 30 minutes, LH: 99 ± 25 minutes; P = .033) and a reduced mean blood loss (LH: 84 ± 57 mL, VH: 178 ± 149 mL; P = .004).
      Eighteen patients in the vaginal group and 17 in the laparoscopic group were eligible for mono- or bilateral adnexectomy. In the laparoscopic hysterectomy arm, bilateral adnexectomy was performed in 100% of patients, when preoperatively planned, as compared with 73% (n = 13) of patients in the vaginal hysterectomy arm (P = .045). The 2 groups were comparable for ultrasound correspondence (95% for each group), additional pathologies found during the operation (6 in vaginal and 7 in laparoscopic arm), intraoperative complications, and unintended laparotomy (none occurred in either group) (Table 2).
      TABLE 2Intraoperative parameters
      Intraoperative parametersLaparoscopyVaginalP value
      Mean operative time ± SD99.3 ± 25.481.95 ± 29.6.033
      Mean blood loss ± SD83.9 ± 57.2178.2 ± 149.4.004
      Adnexial pathology, n9 (30%)8 (26.7%)1.000
      Adnexectomy if preoperatively planned, n17 (100%)13 (73%).045
      Complications, n0 (0%)0 (0%)
      Data are expressed as number (percentage), mean ± SD.
      Candiani. Laparoscopic vs vaginal hysterectomy for benign pathology. Am J Obstet Gynecol 2009.
      Postoperative outcome is illustrated in Table 3. LH was associated with a reduced hospital stay (2.7 ± 0.5 days) as compared with VH (3.2 ± 0.6 days) (P < .001). In particular, we found that more than 33% of patients in the laparoscopic arm could be discharged from the hospital on day 2 vs only 3.3% of patients in the vaginal arm. We described a major complication (thrombosis at day 6) in 1 patient of the vaginal group (P = .173), which was treated with heparin and had a spontaneous resolution. Postoperative pain on day 0 according to the VAS (VH: 5.2 ± 3.4; LH: 2.7 ± 2.8; P = .023) and the number of days of analgesic request were higher in the vaginal group (LH: 0.96; VH: 1.65; P = .017) (Table 3).
      TABLE 3Postoperative parameters and pain (analogic scale)
      Postoperative parametersLaparoscopyVaginalP value
      Mean hospital stay (d) ± SD2.7 ± 0.533.2 ± 0.64< .001
       2, n10 (33.3%)1 (3.3%)
       3, n19 (63.3%)22 (73.3%)
       4, n1 (3.4%)5 (16.6%)
       5, n2 (6.7%)
      Mean delta hemoglobin (g/dL) ± SD-1.25 ± 0.93-1.57 ± 0.72.252
      Restarting urinary function (mean, d)1.64 ± 0.561.86 ± 0.36.132
      Temperature (> 38°C)10%18.8%.660
      Restarting bowel motility (mean, d)1.771.93.336
       1, n10 (33.3%)8 (26.7%)
       2, n17 (56.7%)16 (53.3%)
       3, n3 (10%)6 (20%)
      Major complications
      One patient in the vaginal arm had a major complication (thrombosis at day 6) and was treated with heparin and had a spontaneous resolution.
      0 (0%)1 (3.3%).173
      Pain
       Day 0 (mean ± SD)2.74 ± 2.85.17 ± 3.4.023
       Day 1 (mean ± SD)3.95 ± 3.24.00 ± 2.9.958
       Day 2 (mean ± SD)1.95 ± 1.62.56 ± 2.4.370
       Day 3 (mean ± SD)1.25 ± 1.31.67 ± 1.2.520
       Mean days of analgesic request0.96 ± 0.921.65 ± 0.99.017
      Data are expressed as number (percentage), mean ± SD.
      Candiani. Laparoscopic vs vaginal hysterectomy for benign pathology. Am J Obstet Gynecol 2009.
      a One patient in the vaginal arm had a major complication (thrombosis at day 6) and was treated with heparin and had a spontaneous resolution.
      At the first, sixth, and twelfth month of evaluation, there were no significant differences in gynecological and ultrasound objectivity. In addition, no differences in pelvic pain, urinary dysfunctions, sexual activity, vaginal infections, and the resumption of work were observed (Table 4).
      TABLE 4First-month, 6-month, and 12-month follow-up
      Parameters analyzedFirst monthSix monthsTwelve months
      LaparoscopyVaginalP valueLaparoscopyVaginalP valueLaparoscopyVaginalP value
      N pazienti303025272324
      Genital prolapse, n.141.185.516
       Absence25 (83.3%)22 (73.3%)16 (64%)14 (51.8%)17 (73.9%)15 (62.5%)
       I-II degree5 (16.7%)8 (26.7%)9 (36%)13 (48.2%)6 (26.1%)9 (31.5%)
       III-IV degree0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)
      Urinary problems, n1.0001.0001.000
       Absence28 (93.4%)28 (93.4%)21 (84%)21 (77.8%)20 (87%)21 (87.5%)
       Urgency1 (3.3%)1 (3.3%)2 (8%)3 (11.1%)1 (4.3%)1 (4.2%)
       IUS1 (3.3%)1 (3.3%)2 (8%)3 (11.1%)2 (8.7%)2 (8.3%)
      Sexual activity1.0001.0001.000
       No95%95%0%0%0%0%
       Yes5%5%100%100%100%100%
      Resumption of work, d.689100%100%1.000100%100%1.000
       ≤ 2144%50%
       ≥ 2156%50%
       Mean25.222.6
      Data are expressed as number (percentage).
      Candiani. Laparoscopic vs vaginal hysterectomy for benign pathology. Am J Obstet Gynecol 2009.

      Comment

      There is now a general consensus that vaginal hysterectomy should be considered the gold standard if compared with laparotomic hysterectomy in case of benign uterine pathologies with mobile and no large uterus and without adnexal pathologies.
      • Kovac S.R.
      Guidelines to determine the route of hysterectomy.
      • Sheth S.S.
      Vaginal hysterectomy.
      Such a superiority, however, is not so clearly demonstrated over laparoscopic hysterectomy.
      • Garry R.
      • Fountain J.
      • Mason S.
      • et al.
      The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy.
      • Summitt Jr, R.L.
      • Stoval T.G.
      • Limpscomb G.H.
      • Ling F.W.
      Randomized comparison of laparoscopically assisted vaginal hysterectomy with vaginal standard hysterectomy in an outpatient setting.
      In our prospective study, we randomized 60 patients with an indication to vaginal hysterectomy into 2 groups: vaginal and laparoscopic hysterectomy. Baseline characteristics between the 2 arms did not significantly differ. A slight, albeit not significant, difference was observed for BMI. We consider that the difference is due only to randomization. As a matter of fact, we know that the BMI does not have an impact on the time of surgery, the blood loss, the time of hospitalization, and the intra- and postoperative complication rate in laparoscopic surgery.
      • O'Hanlan K.A.
      • Lopez L.
      • Dibble S.L.
      • Garnier A.C.
      • Huang G.S.
      • Leuchtenberger M.
      Total laparoscopic hysterectomy: body mass index and outcomes.
      • O'Hanlan K.A.
      • Huang G.S.
      • Lopez L.
      • Garnier A.C.
      Selective incorporation of total laparoscopic hysterectomy for adnexal pathology and body mass index.
      In addition to that, based on previous available data, we decided also to include in the study patients with previous cesarean section,
      • Sheth S.S.
      • Malpani A.N.
      Vaginal hysterectomy following previous caesarean section.
      abdominal surgery
      • Doucette R.C.
      • Sharp H.T.
      • Alder S.C.
      Challenging generally accepted contraindications to vaginal hysterectomy.
      (apart for endometriosis or pelvic inflammatory disease surgery), and nulliparity.
      • Agostini A.
      • Bretelle F.
      • Cravello L.
      • Maisonneuve A.S.
      • Roger V.
      • Blanc B.
      Vaginal hysterectomy in nulliparous women without prolapse: a prospective comparative study.
      In the present series, the operating time was shorter for vaginal hysterectomy. This result is consistent with previous reports. The mean difference in the operating time between the vaginal and laparoscopic hysterectomy, however, was in our experience (18 minutes) clearly lower than the values that have been previously reported by other authors (41 minutes
      • Ribiero S.C.
      • Ribiero R.M.
      • Santos S.C.
      • Pinotti J.A.
      A randomised study of total abdominal, vaginal and laparoscopic hysterectomy.
      and 44.5 minutes
      • Johnson N.
      • Barlow D.
      • Lethaby A.
      • Tavender E.
      • Curr L.
      • Garry R.
      Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.
      ).
      We also observed a significant difference in intraoperative blood loss, confirming the findings of Jugnet et al,
      • Jugnet N.
      • Cosson M.
      • Wattiez A.
      • et al.
      Comparing vaginal and celioscopic total or subtotal hysterectomies: prospective multicenter study including 82 patients.
      who reported a blood loss of 182 mL during vaginal hysterectomy vs 98 mL during laparoscopic hysterectomy. We failed to observe a difference when considering the decrease in hemoglobin concentration the first day after surgery (VH: -1.57 g/dL; LH: -1.25 g/dL; P = .252). In comparison, Ribiero et al
      • Ribiero S.C.
      • Ribiero R.M.
      • Santos S.C.
      • Pinotti J.A.
      A randomised study of total abdominal, vaginal and laparoscopic hysterectomy.
      described a higher intraoperative blood loss in the vaginal arm and also found a significantly higher reduction in hemoglobin and hematocrit levels (P = .0001 and P = .0023, respectively). Cosson et al
      • Cosson M.
      • Laumbadie E.
      • Boukerrou M.
      • Querleu D.
      • Crepin G.
      Vaginal, laparoscopic, or abdominal hysterectomies for benign disorders: immediate and early postoperative complications.
      reported a reduction of severe hemorrhages in the vaginal hysterectomy (2%) compared with the celioscopic approach (5.3%) (P = .0001).
      We observed a statistically significant difference in the execution of bilateral adnexectomy when preoperatively planned; this procedure was performed in only 73% of patients in the vaginal arm and in 100% of patients in the laparoscopic arm (P = .045).
      Our data compare favorably with those previously published. Ballard and Walters
      • Ballard L.A.
      • Walters M.D.
      Transvaginal mobilization and removal of ovaries and fallopian tubes after vaginal hysterectomy.
      reported 65% of vaginal salpingo-oophorectomy performed in patients with adnexal pathologies or for prophylaxis. Moreover, even if rare, the procedure could produce a higher risk of hemorrhages.
      • Capen C.V.
      • Irwin H.
      • Magrina I.
      • Masterson B.J.
      Vaginal removal of the ovaries in association with vaginal hysterectomy.
      • Smale L.E.
      • Smale M.L.
      • Wilkening R.L.
      • Mundy C.F.
      • Ewing T.L.
      Salpingo-oophorectomy at the time of vaginal hysterectomy.
      Lambaudie et al
      • Lambaudie E.
      • Occelli B.
      • Boukerrou M.
      • Crepin G.
      • Cosson M.
      Vaginal hysterectomy in nulliparous women: indications and limits.
      observed that only 51.8% of nulliparous women submitted to a vaginal hysterectomy had a supplementary adnexectomy; the authors concluded that in case of an indication of adnexectomy in nulliparous women, laparoscopic access should be preferred. According to Wilcox et al,
      • Wilcox L.S.
      • Koonin L.M.
      • Pokaras R.
      • Strauss L.T.
      • Xia Z.
      • Peterson H.B.
      Hysterectomy in the United States, 1988-1990.
      salpingo-oophorectomy is performed in only 10.3% of patients submitted to vaginal hysterectomy.
      These results appear very far apart from what Davies et al
      • Davies A.
      • O'Connor H.
      • Magos A.L.
      A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy.
      and Kovac and Cruikshank
      • Kovac R.
      • Cruikshank S.H.
      Guidelines to determinate the route of oophorectomy with hysterectomy.
      produced in their studies. The first, in fact, reported that bilateral adnexectomy can be effectively performed in 95-97% of colpohysterectomy. This procedure adds a mean of only 14 minutes to the surgery without any impact on intra- and postoperative complications and time of hospital stay. Kovac and Cruikshank
      • Kovac R.
      • Cruikshank S.H.
      Guidelines to determinate the route of oophorectomy with hysterectomy.
      confirmed the data, emphasizing that 99.9% of ovaries can be removed vaginally. By the analysis of literature,
      • Wilcox L.S.
      • Koonin L.M.
      • Pokaras R.
      • Strauss L.T.
      • Xia Z.
      • Peterson H.B.
      Hysterectomy in the United States, 1988-1990.
      • Lambaudie E.
      • Occelli B.
      • Boukerrou M.
      • Crepin G.
      • Cosson M.
      Vaginal hysterectomy in nulliparous women: indications and limits.
      • Ballard L.A.
      • Walters M.D.
      Transvaginal mobilization and removal of ovaries and fallopian tubes after vaginal hysterectomy.
      • Capen C.V.
      • Irwin H.
      • Magrina I.
      • Masterson B.J.
      Vaginal removal of the ovaries in association with vaginal hysterectomy.
      • Smale L.E.
      • Smale M.L.
      • Wilkening R.L.
      • Mundy C.F.
      • Ewing T.L.
      Salpingo-oophorectomy at the time of vaginal hysterectomy.
      those percentages
      • Davies A.
      • O'Connor H.
      • Magos A.L.
      A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy.
      • Kovac R.
      • Cruikshank S.H.
      Guidelines to determinate the route of oophorectomy with hysterectomy.
      • Paparella P.
      • Sizzi O.
      • Rossetti A.
      • De Benedittis F.
      • Paparella R.
      Vaginal hysterectomy in generally considered contraindications to vaginal surgery.
      appear excessive.
      Bilateral salpingo-oophorectomy is extremely important in peri- and postmenopausal women in which the probability of developing an ovarian cancer is about 1%. This aspect is of particular importance in women with a high risk for that pathology (familiarity for breast or ovarian cancer; previous breast, gastrointestinal, and endometrial cancer). In those groups the probability to detect an occult ovarian cancer is 17%.
      • Rosen B.
      • Kwon J.
      • Fung Kee Fung M.
      • Gagliardi A.
      • Chambers A.
      Systematic review of management options for women with a hereditary predisposition to ovarian cancer.
      Moreover, the execution of prophylactic adnexectomy eliminates the problem of adnexal torsion, benign ovarian pathologies, and prolapsed salpinx (7.91%).
      • Mashiach R.
      • Canis M.
      • Jardon K.
      • Mage G.
      • Pouly J.L.
      • Wattiez A.
      Adnexal torsion after laparoscopic hysterectomy: description of seven cases.
      In the present series, there were no ureteral injuries, incidental cystotomies, or any other intra- and postoperative complications with the exception of a thrombosis at day 6 in 1 patient in the vaginal group who was treated with heparin and had a spontaneous resolution. Similarly, Johnson et al
      • Johnson N.
      • Barlow D.
      • Lethaby A.
      • Tavender E.
      • Curr L.
      • Garry R.
      Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.
      did not report significant differences between the 2 approaches in this respect. Noteworthy is the fact that the rate of complication does not appear to differ between the 2 procedures after concluding the learning curve.
      • Perino A.
      • Cucinella G.
      • Venezia R.
      • Castelli A.
      • Cittadini E.
      Total laparoscopical hysterectomy: an assessment of the learning curve in a prospective randomised study.
      • Makinen J.
      • Johansson J.
      • Tomas C.
      • et al.
      Morbidity of 10,110 hysterectomies by type of approach.
      • Leminen A.
      Comparison between personal learning curves for abdominal and laparoscopic hysterectomy.
      • Claerhout F.
      • Deprest J.
      Laparoscopic hysterectomy for benign diseases.
      In this regard, it must be noted that it has been estimated that about 30 procedures are required to properly perform the procedure.
      Some studies have underlined that the laparoscopic approach is related to a high incidence of ureteral and bladder lesions.
      • Mashiach R.
      • Canis M.
      • Jardon K.
      • Mage G.
      • Pouly J.L.
      • Wattiez A.
      Adnexal torsion after laparoscopic hysterectomy: description of seven cases.
      In addition, Garry et al,
      • Garry R.
      • Fountain J.
      • Mason S.
      • et al.
      The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy.
      in their eVALuate study, reported a similar observation. They presented a concurrent pair of randomized controlled trials to eVALuate the relative roles of Vaginal, Abdominal and Laparoscopic hysterectomy in routine gynecological practice. We believe that their data should be interpreted with caution, because they used different and nonstandardized laparoscopic techniques; in particular, precise information of the technique used is omitted in almost 30% of patients with major complications. Only the standardization of the approach allows the reduction of complications, operative time, and time of learning curve.
      • Wattiez A.
      • Soriano D.
      • Cohen S.B.
      • et al.
      The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases.
      • Malzoni M.
      • Perniola G.
      • Perniola F.
      • Imperato F.
      Optimizing the total laparoscopic hysterectomy for benign uterine pathology.
      We made the evaluation of the postoperative pain (days 0-4) using the VAS score. The results showed a significant difference in the 2 arms at day 0 (P = .023), with greater pain referred by the patients in the vaginal arm (mean 5.17 vs 2.74 of laparoscopy). In the following days there was no significant difference. Moreover, we found a difference in mean days of analgesic request (LH: 0.96 day, VH: 1.65 days; P = .017). Also, the number of tablets and vials requested by the patients was higher in the vaginal arm but not significantly (P = .115). These data are in line with findings reported by Garry et al
      • Garry R.
      • Fountain J.
      • Mason S.
      • et al.
      The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy.
      and by Jugnet et al.
      • Jugnet N.
      • Cosson M.
      • Wattiez A.
      • et al.
      Comparing vaginal and celioscopic total or subtotal hysterectomies: prospective multicenter study including 82 patients.
      The authors did not detect differences in terms of pain referred but stressed the higher request of analgesics by the patients who underwent vaginal hysterectomy during the first 48 hours (P < .0005).
      • Garry R.
      • Fountain J.
      • Mason S.
      • et al.
      The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy.
      • Jugnet N.
      • Cosson M.
      • Wattiez A.
      • et al.
      Comparing vaginal and celioscopic total or subtotal hysterectomies: prospective multicenter study including 82 patients.
      These results may be due to the important traction on the uterus required during vaginal hysterectomy and also to the use of vaginal surgical instruments.
      The mean hospitalization time, in our study, was 2.7 days in the laparoscopic arm vs 3.2 days in the vaginal arm (P < .001). Similar data have been recently reported by Morelli et al
      • Morelli M.
      • Caruso M.
      • Noia R.
      • et al.
      Total laparoscopic hysterectomy versus vaginal hysterectomy: a prospective randomized trial.
      (LH: 2.9 days; VH: 3.3 days). Makinen et al.
      • Makinen J.
      • Johansson J.
      • Tomas C.
      • et al.
      Morbidity of 10,110 hysterectomies by type of approach.
      also found a significant reduction of hospital stay in laparoscopic vs vaginal hysterectomies (LH: 3.4 ± 2 days; VH: 5.9 ± 2.7 days; P < .0001). On the contrary, other studies in the literature did not confirm a significant difference between the approaches.
      • Garry R.
      • Fountain J.
      • Mason S.
      • et al.
      The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy.
      • Richardson R.E.
      • Bournas N.
      • Magos A.L.
      Is laparoscopic hysterectomy a waste of time?.
      • Soriano D.
      • Goldstein A.
      • Lecuru F.
      • Darai E.
      Recovery from vaginal hysterectomy compared with laparoscopically assisted hysterectomy: a prospective, randomised, multicenter study.
      • Summitt Jr, R.L.
      • Stoval T.G.
      • Limpscomb G.H.
      • Ling F.W.
      Randomized comparison of laparoscopically assisted vaginal hysterectomy with vaginal standard hysterectomy in an outpatient setting.
      • Johnson N.
      • Barlow D.
      • Lethaby A.
      • Tavender E.
      • Curr L.
      • Garry R.
      Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.
      • Jugnet N.
      • Cosson M.
      • Wattiez A.
      • et al.
      Comparing vaginal and celioscopic total or subtotal hysterectomies: prospective multicenter study including 82 patients.
      • Claerhout F.
      • Deprest J.
      Laparoscopic hysterectomy for benign diseases.
      • Kovac R.
      Hysterectomy outcomes in patients with similar indications.
      Of note, we found that, using standardized parameters, more than 33% of patients in the laparoscopic arm could be discharged from the hospital at day 2 after surgery vs only 3.3% of patients in the vaginal arm. This evidence, in our opinion, is important in terms of medical cost, patients' recovery, and satisfaction.
      Except for the pain at day 0 and the mean days of analgesic request, there were no significantly different parameters between the 2 groups that could justify a longer stay of the vaginal group patients. Nevertheless, there were some postoperative parameters not individually significant but all in all favorable to a faster discharge for the laparoscopic arm. In particular, we found in vaginal hysterectomies a higher mean of delta hemoglobin (-1.57 vs -1.25); a slower restart of bowel motility and urinary function (1.93 vs 1.77 and 1.86 vs 1.64, respectively); more cases of temperature greater than 38°C (18.8% vs 10%); a higher mean of pain at days 1, 2, and 3; and a higher number of vials requested.
      So, the addition of all these elements has produced a longer hospital stay for the vaginal group and less disease in laparoscopic patients.
      The resumption to work was not significantly different between the groups (mean, VH: 22.6 days; LH: 25.2 days; P = .689). The result is in line with those published in the literature.
      • Johnson N.
      • Barlow D.
      • Lethaby A.
      • Tavender E.
      • Curr L.
      • Garry R.
      Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.
      • Jugnet N.
      • Cosson M.
      • Wattiez A.
      • et al.
      Comparing vaginal and celioscopic total or subtotal hysterectomies: prospective multicenter study including 82 patients.
      These data are well correlated with the absence of differences in pelvic pain evaluated at the first-month follow-up.
      Moreover, no differences were observed in terms of satisfaction and sexuality after the operation in the first 12 months. That result is confirmed by other authors.
      • Garry R.
      • Fountain J.
      • Mason S.
      • et al.
      The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy.
      • Farrell S.A.
      • Keiser K.
      Sexuality after hysterectomy.
      A larger sample size and totally blinded perioperative care would be needed to have the study be more definitive, even if the latter is somewhat difficult.
      In conclusion, our study demonstrates that the choice of the vaginal approach to perform a hysterectomy for benign pathologies does not seem to be so obvious. As a matter of fact, it is true that this approach allows a spinal anesthesia and is associated with a reduced mean surgery time as compared with laparoscopy. However, it is also true that laparoscopic hysterectomy is associated with a reduction of blood loss, postoperative pain, and hospital stay. Furthermore, the laparoscopic approach allows the performance of a bilateral adnexectomy, when indicated, in 100% of cases; this could be of great relevance for the choice of the way to approach a hysterectomy.

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      Linked Article

      • Laparoscopic versus vaginal hysterectomy for benign pathology: Candiani et al
        American Journal of Obstetrics & GynecologyVol. 200Issue 4
        • Preview
          The article below summarizes a roundtable discussion of a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Candiani M, Izzo S, Bulfoni A, Riparini J, Ronzoni S, Marconi A. Laparoscopic versus vaginal hysterectomy for benign pathology. Am J Obstet Gynecol 2009;200:368.e1-368.e7. The full discussion appears at www.AJOG.org , pages e1-e6.
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      • Discussion: ‘Laparoscopic versus vaginal hysterectomy for benign pathology' by Candiani et al
        American Journal of Obstetrics & GynecologyVol. 200Issue 4
        • Preview
          In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Candiani M, Izzo S, Bulfoni A, Riparini J, Ronzoni S, Marconi A. Laparoscopic versus vaginal hysterectomy for benign pathology. Am J Obstet Gynecol 2009;200:368.e1-368.e7.
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      • Laparoscopy vs vaginal hysterectomy with culdolaparoscopy oophorectomy
        American Journal of Obstetrics & GynecologyVol. 202Issue 5
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          I read with interest the work of Candani et al.1 The authors reported that planned adnexectomies were done in 100% of the laparoscopic procedures vs 73% of the vaginal. The increasing experiences in laparoscopic surgeries had led these and other authors to suggest that laparoscopic hysterectomy should be preferred over vaginal hysterectomy, because difficult transvaginal oophorectomies are among the potential benefits of the laparoscopy approach.
        • Full-Text
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