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Taiwanese Journal of Obstetrics &... Dec 2011Laparoscopic hysterectomies increase recently due to several advantages of minimally invasive surgery. Controversy exists for laparoscopic hysterectomies for large uteri... (Review)
Review
Laparoscopic hysterectomies increase recently due to several advantages of minimally invasive surgery. Controversy exists for laparoscopic hysterectomies for large uteri weighing >500g because some reports show increased complications and morbidities and high laparoconversion rate in the past. With familiarity of laparoscopic procedures and progress in surgical techniques, the issue should be discussed and reviewed by evidence again. Hence, we conducted a systematic review of laparoscopic hysterectomies for large uteri.
Topics: Blood Loss, Surgical; Female; Humans; Hysterectomy, Vaginal; Laparoscopy; Organ Size; Postoperative Complications; Uterus
PubMed: 22212310
DOI: 10.1016/j.tjog.2011.10.003 -
Health Technology Assessment... Apr 2011The aim of this project was to determine the clinical effectiveness and cost-effectiveness of hysterectomy, first- and second-generation endometrial ablation (EA), and... (Review)
Review
OBJECTIVE
The aim of this project was to determine the clinical effectiveness and cost-effectiveness of hysterectomy, first- and second-generation endometrial ablation (EA), and Mirena® (Bayer Healthcare Pharmaceuticals, Pittsburgh, PA, USA) for the treatment of heavy menstrual bleeding.
DESIGN
Individual patient data (IPD) meta-analysis of existing randomised controlled trials to determine the short- to medium-term effects of hysterectomy, EA and Mirena. A population-based retrospective cohort study based on record linkage to investigate the long-term effects of ablative techniques and hysterectomy in terms of failure rates and complications. Cost-effectiveness analysis of hysterectomy versus first- and second-generation ablative techniques and Mirena.
SETTING
Data from women treated for heavy menstrual bleeding were obtained from national and international trials. Scottish national data were obtained from the Scottish Information Services Division.
PARTICIPANTS
Women who were undergoing treatment for heavy menstrual bleeding were included.
INTERVENTIONS
Hysterectomy, first- and second-generation EA, and Mirena.
MAIN OUTCOME MEASURES
Satisfaction, recurrence of symptoms, further surgery and costs.
RESULTS
Data from randomised trials indicated that at 12 months more women were dissatisfied with first-generation EA than hysterectomy [odds ratio (OR): 2.46, 95% confidence interval (CI) 1.54 to 3.93; p = 0.0002), but hospital stay [WMD (weighted mean difference) 3.0 days, 95% CI 2.9 to 3.1 days; p < 0.00001] and time to resumption of normal activities (WMD 5.2 days, 95% CI 4.7 to 5.7 days; p < 0.00001) were longer for hysterectomy. Unsatisfactory outcomes associated with first- and second-generation techniques were comparable [12.2% (123/1006) vs 10.6% (110/1034); OR 1.20, 95% CI 0.88 to 1.62; p = 0.2). Rates of dissatisfaction with Mirena and second-generation EA were similar [18.1% (17/94) vs 22.5% (23/102); OR 0.76, 95% CI 0.38 to 1.53; p = 0.4]. Indirect estimates suggested that hysterectomy was also preferable to second-generation EA (OR 2.32, 95% CI 1.27 to 4.24; p = 0.006) in terms of patient dissatisfaction. The evidence to suggest that hysterectomy is preferable to Mirena was weaker (OR 2.22, 95% CI 0.94 to 5.29; p = 0.07). In women treated by EA or hysterectomy and followed up for a median [interquartile range (IQR)] duration of 6.2 (2.7-10.8) and 11.6 (7.9-14.8) years, respectively, 962/11,299 (8.5%) women originally treated by EA underwent further gynaecological surgery. While the risk of adnexal surgery was similar in both groups [adjusted hazards ratio 0.80 (95% CI 0.56 to 1.15)], women who had undergone ablation were less likely to need pelvic floor repair [adjusted hazards ratio 0.62 (95% CI 0.50 to 0.77)] and tension-free vaginal tape surgery for stress urinary incontinence [adjusted hazards ratio 0.55 (95% CI 0.41 to 0.74)]. Abdominal hysterectomy led to a lower chance of pelvic floor repair surgery [hazards ratio 0.54 (95% CI 0.45 to 0.64)] than vaginal hysterectomy. The incidence of endometrial cancer following EA was 0.02%. Hysterectomy was the most cost-effective treatment. It dominated first-generation EA and, although more expensive, produced more quality-adjusted life-years (QALYs) than second-generation EA and Mirena. The incremental cost-effectiveness ratios for hysterectomy compared with Mirena and hysterectomy compared with second-generation ablation were £1440 per additional QALY and £970 per additional QALY, respectively.
CONCLUSIONS
Despite longer hospital stay and time to resumption of normal activities, more women were satisfied after hysterectomy than after EA. The few data available suggest that Mirena is potentially cheaper and more effective than first-generation ablation techniques, with rates of satisfaction that are similar to second-generation techniques. Owing to a paucity of trials, there is limited evidence to suggest that hysterectomy is preferable to Mirena. The risk of pelvic floor surgery is higher in women treated by hysterectomy than by ablation. Although the most cost-effective strategy, hysterectomy may not be considered an initial option owing to its invasive nature and higher risk of complications. Future research should focus on evaluation of the clinical effectivesness and cost-effectiveness of the best second-generation EA technique under local anaesthetic versus Mirena and types of hysterectomy such as laparoscopic supracervical hysterectomy versus conventional hysterectomy and second-generation EA.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Contraceptive Agents, Female; Cost-Benefit Analysis; Endometrial Ablation Techniques; Female; Humans; Hysterectomy; Levonorgestrel; Menorrhagia; Patient Satisfaction; Postoperative Complications; Quality-Adjusted Life Years; Time; Treatment Outcome
PubMed: 21535970
DOI: 10.3310/hta15190 -
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 -
The Cochrane Database of Systematic... Jul 2009The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Female; Genital Diseases, Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Laparoscopy; Randomized Controlled Trials as Topic
PubMed: 19588344
DOI: 10.1002/14651858.CD003677.pub4 -
BMJ Clinical Evidence Nov 2009Prolapse 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 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 14 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; Transplants; Uterine Prolapse; Vagina
PubMed: 21726473
DOI: No ID Found -
BMJ Clinical Evidence May 2007Between 5-77% of women may have fibroids, depending on the method of diagnosis used. Fibroids may be asymptomatic, or may present with menorrhagia, pain, infertility, or... (Review)
Review
INTRODUCTION
Between 5-77% 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 November 2006 (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 41 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.
Topics: Humans; Hysterectomy; Hysterectomy, Vaginal; Leiomyoma; Uterine Neoplasms
PubMed: 19454074
DOI: No ID Found -
BMJ (Clinical Research Ed.) Jun 2005To evaluate the most appropriate surgical method of hysterectomy (abdominal, vaginal, or laparoscopic) for women with benign disease. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the most appropriate surgical method of hysterectomy (abdominal, vaginal, or laparoscopic) for women with benign disease.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, and Biological Abstracts.
SELECTION OF STUDIES
Only randomised controlled trials were selected; participants had to have benign gynaecological disease; interventions had to comprise at least one hysterectomy method compared with another; and trials had to report primary outcomes (time taken to return to normal activities, intraoperative visceral injury, and major long term complications) or secondary outcomes (operating time, other immediate complications of surgery, short term complications, and duration of hospital stay).
RESULTS
27 trials (total of 3643 participants) were included. Return to normal activities was quicker after vaginal than after abdominal hysterectomy (weighted mean difference 9.5 (95% confidence interval 6.4 to 12.6) days) and after laparoscopic than after abdominal hysterectomy (difference 13.6 (11.8 to 15.4) days), but was not significantly different for laparoscopic versus vaginal hysterectomy (difference -1.1 (-4.2 to 2.1) days). There were more urinary tract injuries with laparoscopic than with abdominal hysterectomy (odds ratio 2.61 (95% confidence interval 1.22 to 5.60)), but no other intraoperative visceral injuries showed a significant difference between surgical approaches. Data were notably absent for many important long term patient outcome measures, where the analyses were underpowered to detect important differences, or they were simply not reported in trials.
CONCLUSIONS
Significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it brings a higher chance of bladder or ureter injury.
Topics: Female; Humans; Hysterectomy; Intraoperative Complications; Laparoscopy; Length of Stay; Randomized Controlled Trials as Topic; Treatment Outcome; Urinary Tract
PubMed: 15976422
DOI: 10.1136/bmj.330.7506.1478 -
BMJ (Clinical Research Ed.) Jul 2004To evaluate the incidence and consequences of uterine rupture in women who have had a delivery by caesarean section. (Review)
Review
OBJECTIVE
To evaluate the incidence and consequences of uterine rupture in women who have had a delivery by caesarean section.
DESIGN
Systematic review.
DATA SOURCES
Medline, HealthSTAR, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Centre for Reviews and Dissemination, reference lists, and national experts. Studies in all languages were eligible if published in full.
REVIEW METHODS
Methodological quality was evaluated for each study by using criteria from the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Uterine rupture was categorised as asymptomatic or symptomatic.
RESULTS
We reviewed 568 full text articles to identify 71 potentially eligible studies, 21 of which were rated at least fair in quality. Compared with elective repeat caesarean delivery, trial of labour increased the risk of uterine rupture by 2.7 (95% confidence interval 0.73 to 4.73) per 1000 cases. No maternal deaths were related to rupture. For women attempting vaginal delivery, the additional risk of perinatal death from rupture of a uterine scar was 1.4 (0 to 9.8) per 10,000 and the additional risk of hysterectomy was 3.4 (0 to 12.6) per 10 000. The rates of asymptomatic uterine rupture in trial of labour and elective repeat caesarean did not differ significantly.
CONCLUSIONS
Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.
Topics: Cesarean Section; Cohort Studies; Female; Humans; Incidence; Labor, Induced; Morbidity; Oxytocin; Pregnancy; Prospective Studies; Risk Factors; Trial of Labor; Uterine Rupture
PubMed: 15231616
DOI: 10.1136/bmj.329.7456.19