Surgical approach to hysterectomy for benign gynaecological disease.

The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH). To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms. We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

Aim: The aim of our study was to evaluate the inflammatory response in abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH) techniques using complete blood count (CBC) parameters and to demonstrate the role of the delta neutrophil index (DNI) in hysterectomy types. Materials and Methods: The study included 251 patients. Patients were divided into three groups: AH, VH, and LH. Patient demographic characteristics, operational characteristics, and CBC results (white blood cell (WBC), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and DNI) were compared separately for the three groups before surgery, at 6 hours postoperatively, and at 24 hours postoperatively. Results: The age and menopause rate of patients in the VH (n=84) group were higher than the LH (n=82) and AH (n=84) groups (P < 0.05). The operative time was longest in the LH group and shortest in the AH group (P < 0.05). The highest WBC, NLR, and PLR levels at postoperative 6th hour were in the AH group, and the lowest levels were in the VH group (P < 0.01). There were no significant differences in serum DNI levels between the LH, AH, and VH groups preoperatively and at the 6th and 24th hours postoperatively. Conclusion: We found the highest postoperative inflammatory response in the AH group and the lowest in the VH group, and contrary to many studies, we found that LH patients had an average inflammatory response. Although DNI increased in the postoperative inflammatory process, there was no difference between the AH, LH, and VH groups.

Antibiotic prophylaxis appears to be effective in preventing postoperative infection in women undergoing elective vaginal or abdominal hysterectomy, regardless of the dose regimen. However, evidence is insufficient to show whether use of prophylactic antibiotics influences rates of adverse effects. Similarly, evidence is insufficient to show which (if any) individual antibiotic, dose regimen, or route of administration is safest and most effective. The most recent studies included in this review were 14 years old at the time of our search. Thus findings from included studies may not reflect current practice in perioperative and postoperative care and may not show locoregional antimicrobial resistance patterns.

Trends in hospital readmissions and emergency room visits 60 days after robotic-assisted and laparoscopic hysterectomy

The present study aimed to evaluate surgical operation-related outcomes of laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) for the treatment of benign uterine diseases, other than pelvic organ prolapse, in women aged 65 years or older. Data of women who underwent LH and VH between 2000 and 2013 were compared using propensity-matched analysis. Postoperative complications were graded according to the Accordion Severity Grading. Martin criteria were applied to improve the quality of complications reporting. The study group included 40 propensity-matched participant pairs (80 women) who underwent VH and LH. No significant differences in baseline characteristics were observed between groups. A trend toward longer median operative time was observed in the LH group, in comparison with the VH group (75 [range, 20-340] vs 60 [range, 30-140] min; P = 0.09), whereas LH correlated with shorter hospital stay and lower blood loss in comparison with VH (P < 0.05). One intraoperative complication occurred during VH (bladder injury); no intraoperative complications were recorded in the LH group. No differences in Accordion grade 2 (or worse) postoperative complications were observed (1 of 40 [2.5%] in the LH group vs 3 of 40 [7.5%] in the VH group; P = 0.61; odds ratio, 3.1; 95% CI, 0.3-31.8), and no postoperative deaths occurred. Our findings suggest the noninferiority of LH to VH. LH improves the postoperative course of older women undergoing surgical operation for benign uterine diseases. If an appropriate indication exists, LH should not be denied based on mere chronological age.

Vaginal hysterectomy vs laparoscopic hysterectomy for benign indications: complications and length of stay in a national analysis of contemporary data.

To compare surgical efficacy outcomes and complications after laparoscopic hysterectomy and vaginal hysterectomy performed for benign gynecologic conditions. We performed an online search in major databases, including PubMed, Scopus, Web of Science, ClinicalTrials.gov , and the Cochrane Library from 2000 until February 28, 2023. We searched for randomized controlled trials (RCTs) that compared vaginal hysterectomy with laparoscopic hysterectomy in benign gynecologic conditions. We located 3,249 articles. After reviewing titles and abstracts, we identified 32 articles that were eligible for full-text screening. We excluded nine articles as not-RCT or not comparing vaginal hysterectomy with laparoscopic hysterectomy. Twenty-three articles were included in the final systematic review, with 22 articles included in the meta-analysis. Twenty-three eligible RCTs included a total population of 2,408, with 1,105 in the vaginal hysterectomy group and 1,303 in the laparoscopic hysterectomy group. Blood loss and postoperative urinary tract infection rates were lower in the vaginal hysterectomy group than in the laparoscopic hysterectomy group (mean difference -68, 95% CI -104.29 to -31.7, P <.01, I2 =95% and odds ratio 1.73, 95% CI 0.92-3.26, P =.03, I2 =0%, respectively). Vaginal hysterectomy was associated with less total operative time, less recovery time, and greater postoperative pain on the day of surgery. Other complications, including conversion to laparotomy, visceral organ damage, or wound dehiscence, were uncommon. Because of insufficient data, we were not able to stratify by surgical indication. Vaginal hysterectomy had a shorter total operative time and recovery time but greater postoperative pain on day of surgery compared with laparoscopic hysterectomy. PROSPERO, CRD42023338538.

Trends and Perioperative Outcomes across Elective Benign Hysterectomy Procedures from the ACS-NSQIP 2007–2017

Background This study aimed to compare the clinical outcomes, feasibility, and safety of three minimally invasive hysterectomy techniques—vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and transvaginal natural orifice transluminal endoscopic surgery (vNOTES)—in patients with benign uterine pathologies. Methods This single-center, pragmatic retrospective cross-sectional study was conducted at a tertiary care center in İzmir, Türkiye, between January 2024 and April 2025. A total of 1,146 patients who underwent hysterectomy for benign gynecological indications were included: 298 VH, 730 LH, and 118 vNOTES. Patients with advanced pelvic organ prolapse, severe intra-abdominal adhesions, or incomplete records were excluded. Evaluated outcomes included operative time, estimated blood loss, uterine weight, postoperative pain (visual analogue scale at 12 and 24 hours), complication rates (Clavien–Dindo classification), and length of hospital stay. Results VH had the shortest operative time, while vNOTES was faster than LH. Uterine weight was significantly higher in the LH and vNOTES groups. Postoperative pain at 12 hours was lowest in the vNOTES group, with no significant difference at 24 hours. The vNOTES group demonstrated the lowest overall complication rate (2.5%), and vaginal cuff complications were observed only in the VH and LH groups. Conclusions vNOTES hysterectomy was associated with lower early postoperative pain and fewer complications, supporting its safety and effectiveness in appropriately selected patients. Prospective multicenter studies are warranted to confirm these findings.

Background: The purpose of the study was to compare the postoperative pain intensity between laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH). Materials and methods: In two groups of patients (laparoscopic hysterectomy n=194 – Group A and vaginal hysterectomy n=151 – Group B) we compared average postoperative use of narcotic analgesics by hours in terms of equal dosage and similarity of drugs; we also evaluated postoperative pain intensity by Visual Analogue Scale for Pain (VAS Pain) questionnaire in 24 hours after the intervention. Results and conclusions: Narcotics were used in 31 patients in LH group (15.98%) and 105 patients in VH group (69.54%). Average use of narcotic drugs in LH group was 7:06 hrs, compared to 9:94 hrs in VH group. Postoperative difference in 24 hrs pain intensity was not statistically significant – 1.35 in VH group and 1.12 after LH group. Thus, postoperative pain in first 12 hrs is more intensive after vaginal hysterectomy and lasts longer than after laparoscopic hysterectomy, but in 24 hrs is similar in both groups.

1870 Comparison of Laparoscopic Versus Open Radical Hysterectomy in Early Cervical Cancer after Completing Learning Curve and Reducing Intraperitoneal Tumor Exposure

To compare the in-hospital opioid and non-opioid analgesic use among women who underwent robotic-assisted hysterectomy (RH) vs. open (OH), vaginal (VH), or laparoscopic hysterectomy (LH). Records of women in the United States who underwent hysterectomy for benign gynecologic disease were extracted from the Premier Healthcare Database (2013-2019). Propensity score methods were used to create three 1:1 matched cohorts stratified in inpatients [RH vs. OH (N = 16,821 pairs), RH vs. VH (N = 6149), RH vs. LH (N = 11,250)] and outpatients [RH vs. OH (N = 3139), RH vs. VH (N = 29,954), RH vs. LH (N = 85,040)]. Opioid doses were converted to morphine milligram equivalents (MME). Within matched cohorts, opioid and non-opioid analgesic use was compared. On the day of surgery, the percentage of patients who received opioids differed only for outpatients who underwent RH vs. LH or VH (maximum difference=1%; p<0.001). RH was associated with lower total doses of opioids in all matched cohorts (each p<0.001), with the largest difference observed between RH and OH: median (IQR) of 47.5 (25.0-90.0) vs. 82.5 (36.0-137.0) MME among inpatients and 39.3 (19.5-66.0) vs. 60.0 (35.0-113.3) among outpatients. After the day of surgery, fewer inpatients who underwent RH received opioids vs. OH (78.7 vs. 87.5%; p<0.001) or LH (78.6 vs. 80.6%; p<0.001). The median MME was lower for RH (15.0; 7.5-33.5) versus OH (22.5; 15.0-55.0; p<0.001). Minor differences were observed for non-opioid analgesics. RH was associated with lower in-hospital opioid use than OH, whereas the same magnitude of difference was not observed for RH vs. LH or VH.

In the UK, 56976 hysterectomies were performed in 2012; 62% total abdominal hysterectomy (TAH), 32% vaginal hysterectomy (VH) and 6% laparoscopic hysterectomy (LH) (www.hysterectomy-association.org.uk). Despite the increasing evidence of its clinical and financial merits, LH is yet to be routinely offered. Although patient informed choice and involvement in care plans is a routine practice in the UK, women seem to be denied this when it comes to selecting the route of hysterectomy. One of the key principles for valid consent is discussing all the alternative management strategies with the clinician (RCOG, Clinical governance advice 6, 2015). Certainly, the UK Supreme Court, in its ruling in 2015, did not give a choice for centres or clinicians to deny women their right to get enough information to enable them taking part in the decision (http://supremecourt.uk/decided-cases/index.shtml). A systematic review, including 47 randomised controlled trials (RCTs) with 5102 participants concluded that where VH is not possible LH has advantages over TAH in terms of shorter hospital stay, rapid recovery, and fewer febrile episodes and wound infection. There was no significant difference between VH and LH in terms of return to normal activities, satisfaction, quality of life and surgical complications. The finding of longer operating time and slightly more urinary tract injuries with LH than with TAH reflected the learning curve in the earlier studies, which has been offset by the improvement in skills and advances in technology in more recent years (Aarts et al. Cochrane Database Syst Rev 2015;8:CD003677). The safety assets of LH have also been confirmed in a large RCT (n = 2616) and a meta-analysis (n = 498) reporting a similar rate of intra-operative complications and fewer postoperative complications when compared with TAH. Furthermore, there is adequate evidence on the safety and efficacy of LH for endometrial cancer to support its use [NICE, Interventional procedure guidance (IPG356), 2010]. Many units do not routinely offer LH because of the alleged higher cost and/or the lack of skills. Nevertheless, there is evidence that the cost of consumables is counterbalanced by the shorter hospital stay [NICE, Interventional procedure guidance (IPG356), 2010]. The gynaecologists and stakeholders should learn from the experience of the general surgeons in cholecystectomy and own experience in ectopic pregnancy where the laparoscopic approach has become the norm in the past two decades. Every centre should invest in developing a team for LH of gynaecologists, anaesthetists and nurses, with arrangements in place for clinical governance to optimise outcomes and maximise safety [NICE, Interventional procedure guidance (IPG356), 2010]. The American Association of Gynecologic Laparoscopists (AAGL) stated in 2011 that ‘most hysterectomies for benign indications should be VH or LH and continued efforts should be taken to facilitate these approaches. Gynaecologists without the requisite training and skills should enlist the aid of colleagues who do or refer women to them’. Recent statistics showed rates of LH reaching 20–30% of all hysterectomies in Western Europe and USA with some centres exceeding 70%. This makes us wonder why the UK is lagging behind the developed world (Mäkinen et al. BMJ Open 2013;3:e003169). None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Is laparoscopic hysterectomy a waste of time?

There has been increasing enthusiasm for robotic gynecologic surgery in recent years. Most data supporting robotically assisted hysterectomy for benign gynecologic disease were from small studies conducted in single institutions or centers with surgery performed by highly experienced surgeons. The results of these studies may not be applicable to the practice of gynecology in a community setting. A meta-analysis of randomized trials comparing robotic and laparoscopic surgery for benign gynecologic disease concluded that both procedures were associated with similar outcomes and complications; however, the robotic procedure was considerably more expensive. At present, benefits of robotically assisted hysterectomy for women with benign gynecologic disease are unclear. The aims of this population-based study were to determine rates of uptake of robotically assisted hysterectomy over a 3-year period and to compare the association between use of robotic surgery and rates of abdominal and laparoscopic hysterectomy during this period. In-hospital complications and costs were also compared. The cohort was composed of 264,758 women who underwent hysterectomy for benign gynecologic disorders at 441 hospitals in the United States from 2007 to 2010. The primary outcome measures were uptake of robotic-assisted hysterectomy and factors associated with its utilization. Factors evaluated in the participants included complications, transfusion, reoperation, length of stay, death, and cost. A propensity score–matched analysis was performed to analyze outcomes and minimize selection bias and to estimate the propensity to undergo a robotic-assisted hysterectomy. Uptake of robotically assisted hysterectomy increased rapidly over the 3-year study period from 0.5% to 9.5% of all hysterectomies. Laparoscopic hysterectomy rates during this same time period increased from 24.3% to 30.5%. At hospitals where the robotic procedure was used starting in 2007, it accounted for 22.4% of all hysterectomies by 2010. Increased uptake of robotic-assisted hysterectomy was paralleled by a decrease in the rate of abdominal hysterectomy both in hospitals where robotic-assisted hysterectomy was performed and in those where it was not performed. Propensity score–matched analysis showed similar complication rates for robotic-assisted and laparoscopic hysterectomy (5.5% vs 5.3%); relative risk [RR] was 1.03, with a 95% confidence interval (CI) of 0.86 to 1.24. Hospitalization for longer than 2 days was significantly less common in patients who underwent robotic-assisted hysterectomy compared with the laparoscopic hysterectomy cohort (19.6 vs 24.9%, P < 0.001), whereas there was no difference in the rate of transfusion (1.4% vs 1.8%; RR, 0.80; 95% CI, 0.55–1.16) or the rate of discharge to a nursing facility (0.2% vs 0.3%; RR, 0.79; 95% CI, 0.35–1.76; P > 0.05 for both comparisons). The total costs of robotically assisted hysterectomy per case was more than for laparoscopic hysterectomy; the difference was $2189 (95% CI, $2030–$2349). These data show that the uptake of robotically assisted hysterectomy for benign gynecologic disorders increased substantially between 2007 and 2010. The morbidity profiles for robotically assisted and laparoscopic hysterectomy were similar, but the cost of the robotic procedure was substantially higher.