The best way to determine the best way to undertake a hysterectomy

Abstract

Hysterectomy remains one of the most commonly performed major surgical operations in the developed world. The introduction of laparoscopic techniques to undertake this important procedure has led to a reappraisal of the indications for conventional vaginal hysterectomy (VH) and abdominal hysterectomy (AH) as well as attempts to define the role of the new procedures. Most gynaecologists and their patients would agree that the optimum procedure is the one that can be performed with the greatest safety and produce the greatest relief of symptoms and improvement in quality of life in the most cost-effective manner. How then can we best determine the risks and benefits associated with the various methods of hysterectomy? There are a number of research strategies available, and they all have been used to compare the various methods of hysterectomy. The simplest and most economic is to perform a retrospective analysis of outcomes by retrieving data from the patients’ notes. The paper by Donnez et al.1 in this issue of BJOG is an example of this type of trial. A second approach is to prospectively collect the data required according to a predetermined protocol and to collect all data at the moment the event occurs. The VALUE study2,3 is this type of trial in which a cohort of more than 37 000 women who underwent hysterectomy in England, Wales and Northern Ireland between 1994 and 1995 were studied prospectively. This large, carefully designed study reported that laparoscopic hysterectomy (LH) was associated with double the risk of operative complications associated AH. A third approach is to undertake a prospective randomised controlled trial (RCT) such as the eVALuate study.4–6 A further method of assessing the pros and cons of each method is to undertake a systematic review and meta-analysis of the relevant RCTs.7 This approach obviously requires others to have undertaken a number of suitable RCTs before such a meta-analysis can be undertaken. Each of these methods has strengths and weaknesses. Retrospective trial methodology