Vaginal versus laparoscopic hysterectomy

Editor's note: To see a debate on this topic moderated by Deputy Editor Jon Einarsson, MD, visit www.aagl.org/cobgyn. 

Vaginal hysterectomy: the best minimally invasive approach

By Rosanne M Kho, MD

Dr. Kho is an Associate Professor of Obstetrics and Gynecology at the Mayo Graduate School of Medicine, Mayo Clinic, Rochester, Minnesota.

She has no conflict of interest to disclose with respect to the content of this article.

When a simple hysterectomy is indicated for a benign indication, evidence still indicates that the vaginal route is the route of choice. The latest Cochrane review on the surgical approach to the benign hysterectomy confirmed this from data gathered from 27 randomized trials that involved 3643 patients.¹ Compared to the abdominal approach, vaginal hysterectomy is significantly associated with improved outcomes including shorter length of hospital stay, faster return to normal activity, and less postoperative febrile morbidity.

When comparing vaginal to laparoscopic routes, evidence favors the vaginal approach. At the present time, standard practice guidelines are based upon the Cochrane review, which found that as a group, laparoscopic hysterectomies took longer to perform and were associated with more bleeding than were vaginal hysterectomies. In the Cochrane meta-analysis, laparoscopic hysterectomy took 54 minutes longer than vaginal hysterectomy (95% CI, 43.7–63.5). A subanalysis of laparoscopic versus vaginal hysterectomy found no significant differences in complications, although it included only 2 trials. It is from these findings that the authors went on further to state that laparoscopic hysterectomy should be considered only when vaginal access is not possible.

The available randomized trials evaluating complications between laparoscopic hysterectomy and vaginal hysterectomy show that there are no significant differences. The eVALuate study, involving 2 parallel randomized study arms: laparoscopic hysterectomy versus total abdominal hysterectomy and laparoscopic hysterecotmy versus vaginal hysterectomy, found no difference in the complication rates after the 2 procedures in the vaginal trial (9.8% for laparoscopic hysterectomy, 9.5% for vaginal hysterectomy, mean difference 0.33%, -5.2% to 5.8%, p=0.92; odds ratio 0.97, 0.52 to 1.81). This trial, however, was not powered to detect a difference and its results, therefore, are inconclusive.

Total laparoscopic hysterectomy is thought to be superior to vaginal hysterectomy in its ability to provide better anatomical views and performance of concomitant procedures such as for excision of endometriosis. This is supported in the vaginal arm of the eVALuate study where additional pathology was diagnosed in significantly more patients undergoing laparoscopic hysterectomy (16.4%) than vaginal hysterectomy (4.8%) (P=0.01). The practical significance of this finding, however, remains unclear. To date, we have no studies that evaluate differences in re-operation rates or patient satisfaction scores.

More recently, a meta-analysis was performed that included only RCTs comparing total laparoscopic hysterectomy and vaginal hysterectomy for benign disease.³ This study involved 5 studies (not included in the Cochrane Review) and 332 patients. This meta-analysis confirms previous findings that total laparoscopic hysterectomy  takes longer to perform than vaginal hysterectomy (on average by 30 minutes), and similarly, found no significant difference in the rate of any complication, short-term or long-term, between vaginal hysterectomy and total laparoscopic hysterectomy.

It also found that total laparoscopic hysterectomy was associated with less postoperative pain and decreased length of hospital stay. The authors of this meta-analysis admitted serious limitations to their conclusions including: 1) 3 out of the 5 studies were of moderate methodological quality and 2 were of poor quality; 2) statistical heterogeneity and bias were noted in some of the study outcomes including those of postoperative pain and complications; and 3) the meta-analysis is severely underpowered to detect for rare complications such as lower urinary tract injuries. Given these major limitations, conclusive statements cannot be made and the findings of this meta-analysis should only be interpreted with caution.

It is important to note that, though rare, vaginal cuff dehiscence can be a devastating complication that is notably less in vaginal hysterectomy compared to total laparoscopic hysterectomy.⁴ Ted Lee’s group found that the relative risk of vaginal cuff dehiscence after a total laparoscopic hysterectomy compared to vaginal hysterectomy was 21, a significant difference between the two groups.

A cost-effectiveness analysis undertaken with the eVALuate data revealed that the vaginal approach was more cost-effective compared to the laparoscopic route primarily due to the use of disposable instruments in laparoscopy.⁵ Laparoscopic hysterectomy cost an average of $708 more per patient than vaginal hysterectomy. With still more than 500,000 hysterectomies performed annually in the United States, the vaginal approach is most relevant at this time of cost-containment.

In conclusion, based on evidence, current guidelines advocate that the vaginal route should be approached first for benign hysterectomy whenever feasible. To clarify differences in postoperative pain, patient satisfaction, and return to normal activity, we are still in need of better quality studies to compare vaginal hysterectomy and total laparoscopic hysterectomy. Until these studies become available to reveal otherwise, vaginal hysterectomy remains the route of choice for its advantages with less operative time and cost.

References

1. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2009:CD003677.

2. Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomized trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004;328:129–36.

3. Gendy R, Walsh CA, Walsh SR, Karantanis E. Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metanalysis of randomized controlled trials. AJOG. 2011;204:388

4. Hur HC, Guido RS, Mansuria SM, et al. Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies. JMIG. 2007;114(3):311–317.

5. Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomized trial. BMJ. 2004;328:134–40.

Next: Dr. Ted Lee and Dr. Cara King on the laparoscopic approach

Laparoscopic hysterectomy: the new gold standard

By Ted Lee, MD and Cara R. King, DO

Dr. Lee is the Director of Minimally Invasive Gynecologic Surgery of University of Pittsburgh Medical Center at Magee Womens Hospital.

He reports receiving salary/honoraria and/or consulting fees from Ethicon Endo-Surgery.

Dr. King is a Minimally Invasive Gynecologic Surgery Fellow at Magee Womens Hospital.

She has no conflict of interest to disclose with respect to the content of this article.

The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion #444, “Choosing the Route of Hysterectomy for Benign Disease,” states that vaginal hysterectomy is the approach of choice whenever feasible.¹ In cases in which vaginal hysterectomy is not indicated or achievable, laparoscopic hysterectomy serves as an alternative to abdominal hysterectomy. Many of us who routinely perform minimally invasive surgery are glad that our professional society has finally acknowledged what we have known all along: Abdominal hysterectomy should be minimized.

Vaginal hysterectomy has consistently been considered the gold standard when it comes to a minimally invasive approach to hysterectomy. This has not changed over the years despite the introduction of a laparoscopic technique. In the most recent study by Wright et al., abdominal hysterectomies continued to account for 41% of all hysterectomies in 2010, whereas laparoscopic hysterectomy accounted for 30%, vaginal hysterectomy for 20%, and robotic assisted hysterectomy for 10% of all hysterectomies.²

One of the reasons behind the slow adoption of laparoscopic hysterectomy during the past decade may be that many gynecologists did not readily recognize the benefits or feasibility of laparoscopy. Of course, this is not the only reason that laparoscopic hysterectomy was not adopted more widely. For many years after its introduction, laparoscopic hysterectomy was ridiculed by mainstream ob/gyn academicians. Until recently, recruiting faculty with expertise in advanced laparoscopic surgery was rarely a priority for most US ob/gyn department chairmen.

There are multiple reasons why vaginal hysterectomy has consistently been considered the gold standard in minimally invasive approaches to hysterectomy. A primary advantage is that with no abdominal incisions, it is undeniably the most cosmetic among the different types of hysterectomies. It is also the least costly of the different types of hysterectomies.³ However, this cost margin is greatly reduced when reusable instruments are implemented and the average length of stay for laparoscopic hysterectomies is taken into account. The decreased length of stay for laparoscopic hysterectomies as compared to vaginal hysterectomies is largely attributable to reduced postoperative pain. Several trials comparing postoperative pain in laparoscopic and vaginal hysterectomies have shown that patients who undergo laparoscopic hysterectomy consistently have decreased pain scores.^{4, 5}

Operative time and complication rates are additional comparative measures that have been used to critique these 2 minimally invasive approaches. In the meta-analysis by Gendy et al, laparoscopic hysterectomy was found to take longer than vaginal hysterectomy;⁶ however, significant heterogeneity was found between trials. In general, operative time is largely surgeon- and team-dependent. In regard to complication rate, current literature has found no significant difference between these 2 modalities.⁵ Earlier studies that found significantly higher rates of complications associated with laparoscopic hysterectomy did not take into account the natural learning curve associated with the application of a novel procedure.

Vaginal surgery has inherent limitations, including anatomical factors and underlying disease states. It is interesting to note that all of the randomized trials within the meta‐analysis performed by Gendy et al listed similar exclusion criteria.⁶ Furthermore, even if a vaginal route is feasible, specific underlying comorbidities make it an inappropriate technique. Using endometriosis as an example, a vaginal approach would preclude an adequate evaluation of the pelvis and make complete excision of endometriosis impossible. Essentially, there are exquisitely few limitations in terms of hysterectomy complexity in the hands of a skilled laparoscopic surgeon; however, limitations exist innately in vaginal surgery despite excellent surgical skill.

An additional reality that must be acknowledged is that many residents are not graduating with surgical competency in all hysterectomy techniques. The Accreditation Council for Graduation Medical Education guidelines require that obstetric and gynecology residents perform at least 15 total vaginal hysterectomies prior to graduation.⁷ This scant minimum is quite difficult to achieve for many residents; Tu et al found that on average, teaching hospitals are performing only 13% of their hysterectomies vaginally.⁸ In addition, it has been found that residents require approximately 21‐27 vaginal cases to gain competence.⁹ In fact, when questioned, only 41.7% of 2011 graduating residents reported vaginal hysterectomy as their preferred route of hysterectomy, as compared to 47.1% who preferred laparoscopic approaches.¹⁰

Ideally, all gynecologists should be proficient in both laparoscopic and vaginal hysterectomies. In reality, this expectation is simply not possible in the context of current ob/gyn training and clinical practice. Efforts to promote both vaginal hysterectomy and laparoscopic hysterectomy will ultimately only contribute to the slow decline of abdominal hysterectomy.

Given its versatility, laparoscopic hysterectomy should be the new gold standard in minimally invasive approaches. Professional societies such as ACOG and AAGL should direct more of their resources to promote education in and practice of laparoscopic hysterectomy if a substantial decrease in abdominal hysterectomy is truly our primary goal.

References

1. ACOG Committee Opinion No. 444. Choosing the Route of Hysterectomy for Benign Disease. American College of Obstetricians and Gynecologists. Available at: http://www.acog.org.

2. Wright J, Ananth C, Lewin S, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689‐698.

3. Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from randomized trial. BMH. 2004;328:134.

4. Candiani M, Izzo S, Bulfoni A, Riparini J, Ronzoni S, Marconi A. Laparoscopic vs vaginal hysterectomy for benign pathology. Am J Obstet Gynecol. 2009 April 368.e1‐e7.

5. Ghezzi F, Uccella S, Cromi A, et al. Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial. Am J Obstet Gynecol. 2010 August 118.e1‐e8.

6. Gendy R, Walsh CA, Walsh SR, Karantanis E. Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials. Am J Obstet Gynecol. 2011;204(5):388.e1‐8. Epub 2011 Mar 4.

7. Accreditation Council for Graduate Medical Education, 2012. www. acgme.org. Accessed June 30, 2013.

8. Tu FF, Beaumont JL, Senapati S, et al. Route of hysterectomy influence and teaching hospital status. Obstet Gynecol. 2009;114:73‐78.

9. Jelovsek JE, Walters MD, Korn A, et al. Establishing cutoff scores on assessments of surgical skills to determine surgical competence. Am J Obstet Gynecol. 2010;203:81.e1-e6.

10. Antosh D, Gutman R, Iglesia C, Sokol A, Park A. Resident opinions on vaginal hysterectomy training. Female Pelvic Med Reconstr Surg. 2011;17(6):314-317.