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Obstetrics and Gynecology May 2024To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint.
OBJECTIVE
To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint.
DATA SOURCES
PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible.
METHODS OF STUDY SELECTION
This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy.
TABULATION, INTEGRATION, AND RESULTS
The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss.
CONCLUSION
Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42021233300.
PubMed: 38743951
DOI: 10.1097/AOG.0000000000005607 -
Surgical Technology International Mar 2014In this review we focus on the transvaginal meshes used for pelvic organ prolapse (POP) repair and possible changes in application after the first FDA warning in 2008. A... (Review)
Review
In this review we focus on the transvaginal meshes used for pelvic organ prolapse (POP) repair and possible changes in application after the first FDA warning in 2008. A systematic review of the literature was performed. The data was reviewed for reoperation rates and complications following the Clavien-Dindo classification. A total of 11 randomized controlled and 9 prospective studies with 2,289 patients (most POP-Q ≥ II, median follow-up 12 mos) were included. The results showed a mean total complication rate of 27% in anterior, 20% in posterior, and 40% in combined mesh repair group (ns). Grade ≥ III complications occurred in 8% anterior, 3.5% posterior, and 13% combined (p < 0.05) mesh repairs. No differences were found for reoperation rates for POP (2% to 3%). The following risk factors for complications were identified: operative technique, surgeon experience, previous prolapse repair, concomitant hysterectomy, total mesh repair, mesh properties (light weight, collagen coating were positive factors), young age, sexual activity, and smoking. Due to high complication rates (especially mesh erosion, voiding dysfunction, and dyspareunia) a careful individualized selection of patients and materials, education of patients, and elimination of identified risk factors are urgent prior to implantation of vaginal meshes.
Topics: Female; Humans; Pelvic Organ Prolapse; Postoperative Complications; Reoperation; Surgical Mesh; Vagina
PubMed: 24700225
DOI: No ID Found -
International Journal of Gynaecology... Jan 2023To evaluate the efficacy and safety of five different approaches to cervical cancer surgery. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the efficacy and safety of five different approaches to cervical cancer surgery.
METHODS
We conducted a systematic search for comparative studies on different radical hysterectomy types for cervical cancer in PubMed, Embase, the Cochrane Library, and Web of Science databases. All included observational studies used survival analyses to compare clinical outcomes of patients undergoing different radical hysterectomy types. All studies were assessed by the Newcastle-Ottawa Scale with scores of at least seven points. We extracted the relevant data and conducted a network meta-analysis to compare clinical outcomes among five surgical approaches.
RESULTS
Thirty studies (n = 11 353) were included. Robotic surgery had the lowest blood loss volume and hospitalization duration; open surgery had the shortest operative time. Vaginal assisted laparoscopic surgery was associated with the highest number of resected lymph nodes and lowest rate of perioperative complications. Survival outcomes and tumor recurrence outcomes were similar among the approaches.
CONCLUSION
The current approaches to cervical cancer surgery have comparable efficacies.
Topics: Female; Humans; Uterine Cervical Neoplasms; Network Meta-Analysis; Neoplasm Recurrence, Local; Hysterectomy; Robotic Surgical Procedures; Laparoscopy; Neoplasm Staging
PubMed: 35373333
DOI: 10.1002/ijgo.14209 -
Obstetrics and Gynecology Feb 1997To complete a systematic review of the published literature comparing complications, postoperative recovery time, and costs following laparoscopy-assisted vaginal... (Comparative Study)
Comparative Study Review
OBJECTIVE
To complete a systematic review of the published literature comparing complications, postoperative recovery time, and costs following laparoscopy-assisted vaginal hysterectomy, total abdominal hysterectomy (TAH), and vaginal hysterectomy.
DATA SOURCES
We searched MEDLINE and several bibliographies, identifying all reports using the term "laparoscopy-assisted hysterectomy" published from 1989 to September 1995.
METHODS OF STUDY SELECTION
We excluded case reports, letters, and reports of laparoscopy-assisted vaginal hysterectomy procedures used for radical cancer surgery, sex-change operations, total laparoscopic hysterectomy, or supracervical hysterectomy.
TABULATION, INTEGRATION, AND RESULTS
Cases identified included 3112 laparoscopy-assisted vaginal hysterectomies, 1618 TAHs, and 690 vaginal hysterectomies. Laparoscopy-assisted vaginal hysterectomy cases compared with TAH cases demonstrated significantly greater incidence of bladder injury (1.8% for laparoscopy-assisted vaginal hysterectomy versus 0.4% for TAH; P = .01), significantly longer operating room time (115 minutes, standard deviation [SD] 37 minutes, for laparoscopy-assisted vaginal hysterectomy versus 87 minutes, SD 18 minutes, for TAH; P < .001), and significantly shorter hospitalization (49 hours, SD 16 hours, for laparoscopy-assisted vaginal hysterectomy versus 79 hours, SD 20 hours, for TAH; P < .001). Use of analgesia was consistently less for laparoscopy-assisted vaginal hysterectomy and return to full activity was always sooner when compared to TAH. Cost for the new procedure was higher in seven out of 11 studies, but when disposable instruments and hospital length of stay are considered, the remaining four studies reported a lower cost for laparoscopy-assisted vaginal hysterectomy.
CONCLUSION
Although laparoscopy-assisted vaginal hysterectomy involves a shorter hospital stay, speedier postoperative recovery, and less analgesia use, there is also a higher rate of bladder injury and lengthier surgery. These outcomes must be weighed when choosing an intervention.
Topics: Female; Humans; Hysterectomy, Vaginal; Laparoscopy; Pain, Postoperative; Postoperative Complications
PubMed: 9015041
DOI: 10.1016/S0029-7844(96)00315-8 -
Frontiers in Surgery 2021To provide updated evidence on comparative efficacy for clinical outcomes of radical trachelectomy and radical hysterectomy in patients with early-stage cervical...
To provide updated evidence on comparative efficacy for clinical outcomes of radical trachelectomy and radical hysterectomy in patients with early-stage cervical cancer. A systematic search was conducted in the PubMed, Scopus, Cochrane Database of Systematic Reviews, and Google scholar databases. Studies were done in patients with early-stage cervical cancer that compared the outcomes between radical trachelectomy (RT) and hysterectomy (RH) were considered for inclusion in the review. The outcomes of interest were operative time, the volume of blood loss, need for blood transfusion, any complications, length of hospital stay, risk of recurrence, and survival. The strength of association was presented in the form of pooled relative risk (RR), hazards risk (HR), and weighted mean difference (WMD). Statistical analysis was done using STATA version 16.0. A total of 12 articles were included in the meta-analysis. The majority were retrospective cohort-based studies. Compared to RH, the operative time (in min) was comparatively higher in RT (WMD 23.43, 95% CI: 5.63, 41.24). Patients undergoing RT had blood loss (in ml) similar to those undergoing RT (WMD -81.34, 95% CI: -170.36, 7.68). There were no significant differences in the risk of intra-operative (RR 1.61, 95% CI: 0.49, 5.28) and post-operative complications (RR 1.13, 95% CI: 0.54, 2.40) between the two groups. Patients in the RT group had lesser duration of post-operative hospital stay (in days) (WMD -1.65, 95% CI: -3.22, -0.09). There was no statistically significant difference in the risk of recurrence (HR 1.21, 95% CI: 0.68, 2.18), 5-year overall survival (HR 1.00, 95% CI: 0.99, 1.02), and recurrence-free survival (HR 0.99, 95% CI: 0.96, 1.01) between the two groups. Among the patients with early-stage cervical cancer, RT is similar to RH in safety and clinical outcomes. Future studies with a randomized design and larger sample sizes are needed to further substantiate these findings.
PubMed: 34859038
DOI: 10.3389/fsurg.2021.735944 -
BMJ Clinical Evidence Mar 2012Prolapse of the uterus or vagina is usually the result of loss of pelvic support, and causes mainly non-specific symptoms. It may affect over half of women aged 50 to 59... (Review)
Review
INTRODUCTION
Prolapse of the uterus or vagina is usually the result of loss of pelvic support, and causes mainly non-specific symptoms. It may affect over half of women aged 50 to 59 years, but spontaneous regression may occur. Risks of genital prolapse increase with advancing parity and age, increasing weight of the largest baby delivered, and hysterectomy.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of non-surgical treatments in women with genital prolapse? What are the effects of surgical treatments in women with anterior vaginal wall prolapse? What are the effects of surgical treatments in women with posterior vaginal wall prolapse? What are the effects of surgical treatments in women with upper vaginal wall prolapse? What are the effects of using different surgical materials in women with genital prolapse? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 15 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: abdominal Burch colposuspension; abdominal sacral colpopexy; abdominal sacrohysteropexy; anterior colporrhaphy with mesh reinforcement; laparoscopic surgery; mesh or synthetic grafts; native (autologous) tissue; open abdominal surgery; pelvic floor muscle exercises; posterior colporrhaphy (with or without mesh reinforcement); posterior intravaginal slingplasty (infracoccygeal sacropexy); sacrospinous colpopexy (vaginal sacral colpopexy); sutures; traditional anterior colporrhaphy; transanal repair; ultralateral anterior colporrhaphy alone or with cadaveric fascia patch; vaginal hysterectomy; vaginal oestrogen; vaginal pessaries; and vaginal sacrospinous colpopexy.
Topics: Female; Gynecologic Surgical Procedures; Humans; Hysterectomy, Vaginal; Incidence; Pelvic Floor; Prolapse; Surgical Mesh; Uterine Prolapse; Vagina
PubMed: 22414610
DOI: No ID Found -
Archives of Gynecology and Obstetrics Sep 2021Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome... (Meta-Analysis)
Meta-Analysis Review
Protective operative techniques in radical hysterectomy in early cervical carcinoma and their influence on disease-free and overall survival: a systematic review and meta-analysis of risk groups.
PURPOSE
Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome for open versus minimal invasive surgery, however, the reasons remain to be speculated. This meta-analysis evaluates the outcomes of robotic and laparoscopic hysterectomy compared to open hysterectomy. Risk groups including the use of uterine manipulators or colpotomy were created.
METHODS
Ovid-Medline and Embase databases were systematically searched in June 2020. No limitation in date of publication or country was made. Subgroup analyses were performed regarding the surgical approach and the endpoints OS and DFS.
RESULTS
30 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Patients were analyzed concerning the surgical approach [open surgery (AH), laparoscopic surgery (LH), robotic surgery (RH)]. Additionally, three subgroups were created from the LH group: the LH high-risk group (manipulator), intermediate-risk group (no manipulator, intracorporal colpotomy) and LH low-risk group (no manipulator, vaginal colpotomy). Regarding OS, the meta-analysis showed inferiority of LH in total over AH (0.97 [0.96; 0.98]). The OS was significantly higher in LH low risk (0.96 [0.94; 0.98) compared to LH intermediate risk (0.93 [0.91; 0.94]). OS rates were comparable in AH and LH Low-risk group. DFS was higher in the AH group compared to the LH group in general (0.92 [95%-CI 0.88; 0.95] vs. 0.87 [0.82; 0.91]), whereas the application of protective measures (no uterine manipulator in combination with vaginal colpotomy) was associated with increased DFS in laparoscopy (0.91 [0.91; 0.95]).
CONCLUSION
DFS and OS in laparoscopy appear to be depending on surgical technique. Protective operating techniques in laparoscopy result in improved minimal invasive survival.
Topics: Carcinoma, Squamous Cell; Colpotomy; Early Detection of Cancer; Female; Humans; Hysterectomy; Laparoscopy; Minimally Invasive Surgical Procedures; Pregnancy; Uterine Cervical Neoplasms
PubMed: 34021804
DOI: 10.1007/s00404-021-06082-y -
BMJ Clinical Evidence Jan 2011Between 5% and 77% of women may have fibroids, depending on the method of diagnosis used. Fibroids may be asymptomatic, or may present with menorrhagia, pain,... (Review)
Review
INTRODUCTION
Between 5% and 77% of women may have fibroids, depending on the method of diagnosis used. Fibroids may be asymptomatic, or may present with menorrhagia, pain, infertility, or recurrent pregnancy loss. Risk factors for fibroids include obesity, having no children, and no long-term use of the oral contraceptive pill. Fibroids tend to shrink or fibrose after the menopause.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: medical treatment alone; preoperative medical treatments for women scheduled for surgery; and surgical treatments in women with fibroids? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 54 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: gonadorelin analogues (with progestogen, raloxifene, tibolone, or combined oestrogen-progestogen), hysterectomy (plus oophorectomy), hysteroscopic resonance-focused ultrasound, laparoscopic myomectomy, laparoscopically assisted vaginal hysterectomy, rollerball endometrial ablation, thermal balloon ablation, thermal myolysis with laser, total abdominal hysterectomy, total abdominal myomectomy, total laparoscopic hysterectomy, total vaginal hysterectomy, and uterine artery embolisation.
Topics: Humans; Leiomyoma; Menopause; Pain; Premenopause; Progestins; Raloxifene Hydrochloride; Regression Analysis; Uterine Neoplasms
PubMed: 21477393
DOI: No ID Found -
International Urogynecology Journal Apr 2023This systematic review (PROSPERO:CRD42022275789) is aimed at comparing qualitatively the success, recurrence, and complication rates of sacrocolpopexy with concomitant... (Review)
Review
INTRODUCTION AND HYPOTHESIS
This systematic review (PROSPERO:CRD42022275789) is aimed at comparing qualitatively the success, recurrence, and complication rates of sacrocolpopexy with concomitant hysterectomy, hysteropexy, sacrospinous fixation (SSF) with and without vaginal hysterectomy (VH) and uterosacral fixation (USF) with and without VH.
METHODS
A systematic search was performed using Embase, PubMed, Scopus, and Cochrane databases for studies published from 2011, on women with apical pelvic organ prolapse requiring surgical interventions. Risk of bias was assessed via the National Institutes of Health study quality assessment tool. The primary outcomes are the success and recurrence rate of each technique, for ≥12 months' follow-up. Findings were summarised qualitatively.
RESULTS
A total of 21 studies were included. Overall significant findings for a high success and low recurrence rate are summarised as: minimally invasive sacrocolpopexy (MISC) is superior to abdominal sacrocolpopexy (ASC); sacrospinous hysteropexy (SSHP) is superior to USF + VH, which is superior to uterosacral hysteropexy and mesh hysteropexy (MHP). Significant findings related to complications include: MISC recorded a lower overall complication rate than ASC except in mesh exposure; USF + VH tends to perform better than SSHP and SSF, with SSHP performing better than MHP in faecal incontinence and overactive bladder rates.
CONCLUSION
There is no evidence to conclude that hysterectomy is superior to uterine-sparing approaches. MISC should be considered over ASC given similar efficacy and reduced complications. Superiority of MHP is unproven against native tissue hysteropexy. Further studies under standardised settings are required for direct comparisons between the surgical management methods.
Topics: Female; Humans; Gynecologic Surgical Procedures; Treatment Outcome; Pelvic Organ Prolapse; Uterus; Hysterectomy
PubMed: 36462058
DOI: 10.1007/s00192-022-05408-x -
Journal of Minimally Invasive Gynecology 2019Hysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify... (Meta-Analysis)
Meta-Analysis Review
STUDY OBJECTIVE
Hysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify nonhormonal interventions, perioperative surgical interventions, and devices to minimize blood loss at the time of hysterectomy for leiomyoma.
DATA SOURCES
Librarian-led search of Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases from 1946 to 2018 with hand-guided updates.
METHODS OF STUDY SELECTION
Included studies reported on keywords of hysterectomy, leiomyoma, and operative blood loss/postoperative hemorrhage/uterine bleeding/metrorrhagia/hematoma. The review excluded a comparison of route of hysterectomy, morcellation, vaginal cuff closure, hormonal medications, vessel sealing devices for vaginal hysterectomy, and case series with <10 patients.
TABULATION, INTEGRATION, AND RESULTS
Surgical blood loss, postoperative hemoglobin (Hb) drop, hemorrhage, transfusion, and major and minor complications were analyzed and aggregated in meta-analyses for comparable studies in each category. A total of 2016 unique studies were identified, 33 of which met the inclusion criteria, and 22 were used for quantitative synthesis. The perioperative use of misoprostol in abdominal hysterectomy (AH) was associated with a lower postoperative Hb drop (0.59 g/dL; 95% confidence interval [CI], 0.39-0.79; p < .01) and blood loss (-96.43 mL; 95% CI, -153.52 to -39.34; p < .01) compared with placebo. Securing the uterine vessels at their origin in laparoscopic hysterectomy (LH) was associated with decreased intraoperative blood loss (-69.07 mL; 95% CI, -135.20 to -2.95; p = .04) but no significant change in postoperative Hb (0.24 g/dL; 95% CI, -0.31 to 0.78; p = .39) compared with securing them by the uterine isthmus. Uterine artery ligation in LH before dissecting the ovarian/utero-ovarian vessels was associated with lower surgical blood loss compared with standard ligation (-27.72 mL; 95% CI, -35.07 to -20.38; p < .01). The postoperative Hb drop was not significantly different with a bipolar electrosurgical device versus suturing in AH (0.26 g/dL; 95% CI, -0.19 to 0.71; p = .26). There was no significant difference between an electrosurgical bipolar vessel sealer (EBVS) and conventional bipolar electrosurgical devices in the Hb drop (0.02 g/dL; 95% CI, -0.15 to 0.20; p = .79) or blood loss (-50.88 mL; 95% CI, -106.44 to 4.68; p = .07) in LH. Blood loss in LH was not decreased with the LigaSure (Medtronic, Minneapolis, MN) impedance monitoring EBVS compared with competing EBVS systems monitoring impedance or temperature (2.00 mL; 95% CI, -8.09 to 12.09; p = .70). No significant differences in hemorrhage, transfusion, or major complications were noted for all interventions.
CONCLUSION
Perioperative misoprostol in AH led to a reduction in surgical blood loss and postoperative Hb drop (moderate level of evidence by Grading of Recommendations, Assessment, Development and Evaluation guidelines) although the clinical benefit is likely limited. Remaining interventions, although promising, had at best low-quality evidence to support their use at this time. Larger and rigorously designed randomized trials are needed to establish the optimal set of perioperative interventions for use in hysterectomy for leiomyomas.
Topics: Blood Loss, Surgical; Female; Humans; Hysterectomy; Leiomyoma; Perioperative Care; Treatment Outcome; Uterine Neoplasms
PubMed: 31039407
DOI: 10.1016/j.jmig.2019.04.021