Examining the Evidence
Laparoscopy: Desirable for most hysterectomy patients
To compare laparoscopic, abdominal, and vaginal hysterectomy, with major and minor complications as the primary endpoints.
The laparoscopic group had less pain, quicker recovery, and better short-term quality of life than the abdominal group, but a significantly greater rate of major complications and operating time. Complication rates were similar for laparoscopic and vaginal hysterectomy, though that arm was underpowered.
This is one of only a few randomized, controlled trials comparing the 3 hysterectomy techniques. Women were randomized to laparoscopic (n = 391) versus abdominal (n = 172) hysterectomy (abdominal arm) or to laparoscopic (n = 198) versus vaginal (n = 105) hysterectomy (vaginal arm).
Study strengths and findings. Design was excellent, and investigators reported results of both trial arms, though insufficient numbers were recruited in the vaginal arm. Thus, we can draw reasonable conclusions from the large number of women involved:
- Operating time. Longer with laparoscopic than with abdominal or vaginal hysterectomy.
- Quality of life. Significantly improved with laparoscopic hysterectomy up to 1 year.
- Minor complications. Similar in all groups.
- Detection of additional pathology. Greater with laparoscopy. Surprisingly, in the abdominal arm, additional pathology was reported in 12.7% of patients versus 22.6% for the laparoscopic approach. In the vaginal arm, additional pathology was detected in 4.8% of cases versus 16.4% for the laparoscopic approach.
- Pain. Less with laparoscopy in the abdominal arm, but comparable in the vaginal arm.
Weaknesses. Some shortcomings in study design were largely unavoidable. For example, by excluding patients with prolapse or with a uterus larger than 12 weeks’ gestation, researchers limited generalizability, as these conditions are common indications for hysterectomy in a typical clinical practice, and frequently are determinants of the approach.
The incidence of major hemorrhage (abdominal arm: 2.4%, versus 4.6% for laparoscopy; vaginal arm: 2.9%, versus 5.1% for laparoscopy) may have been related to the method of utero-ovarian vessel ligation and sealing, but no description or standardization was offered. Thus, it is unclear whether a simple alteration in technique could have eliminated this as a factor in morbidity.
Unintended laparotomy was considered a major complication in this study, but only in the laparoscopy groups. Excluding this, major complications would have been lower in the laparoscopy group compared with the abdominal group. It seems inappropriate to consider a procedure that is standard for 1 group as a major complication in another.
Taken with existing literature, this study supports the premise that laparoscopy is desirable for most women undergoing hysterectomy. It also confirms the superiority of laparoscopic hysterectomy in recognizing and treating other pathology while ensuring a shorter recovery and hospital stay and improved quality of life.