Hysterectomy is one of the most frequently performed major surgical procedure among reproductive-aged women. In the United States, approximately 600 000 hysterectomies are performed each year.1 Traditionally, the majority of hysterectomies have been performed abdominally. The disadvantage of total abdominal hysterectomy (TAH) includes larger abdominal incisions, more interference of the abdomen and a prolonged recovery period. Laparoscopic assisted vaginal hysterectomy (LAVH) and total vaginal hysterectomy (TVH) are becoming more popular with gynecologists. LAVH and TVH have begun to replace the TAH procedure. What is the clinical outcome for these three routes? What are the indications for different routes? Our study aimed to compare the clinical outcomes of TAH, TVH and LAVH regarding operation time, blood loss, postoperative pain, and hospital stay.
We chose the different routes of hysterectomy for myoma in the Peking Union Medical College Hospital from 2004 to 2007. All patients had indication for hysterectomy. This study was approved by the Institutional Ethics Committee of Peking Union Medical College Hospital. The indication of uterine volume is 10–12 gestational weeks in our study. One hundred and one women undergoing hysterectomy for myoma were randomized to three groups, 34 cases were performed by LAVH, 35 cases by TVH and 32 by TAH.
Patients were of reproductive age and had delivered at least one child. Surgical history: 3 patients had a history of cesarean section and 1 had had an appendectomy in the TAH group; 2 patients had had cesarean sections and 1 had had an appendectomy in the LAVH group; 2 had had appendectomy in the TVH group. Seven cases had a salpingo-oophorectomy performed at the time of hysterectomy for ovarian cysts in the TAH group, and 6 cases in the TVH group. The diameter of the ovarian cysts were less than 6 cm and no adhesions were found in the pelvis. Ovarian benign cyst and uterine myoma had been confirmed by pathology. The average weight of the uterus was (272.25±20.09) g in the TAH group, versus (234.93±21.25) g in the LAVH group and (268.00±32.62) g in the TVH group. There was no significant difference among the three groups (P >0.05). In an effort to minimize the “learning curve” effects on the outcome, two senior gynecologists performed all operations.
All TAH, with and without salpingo-oophorectomy procedures, were performed utilizing a standard technique. All laparoscopic procedures were performed in a modified lithotomy position using a video-monitor to record the laparoscopic part of the operation. A 10-mm laparoscope was inserted in the standard sub-umbilical position. Second and third entries were made suprapubically on both sides, corresponding to the lateral ends of a Pfannenstiel incision. Round ligaments, tubes and utero-ovarian ligaments were diathermy and cut when the adnexa were to be preserved, while the round and infundibulo-pelvic ligaments were diathermy and cut when the adnexa were to be removed. The uterovesical fold of the peritoneum was divided by scissors. The uterine artery and the partial cardinal and uterosacral ligament were diathermy and cut. The cervix was circumcised and the pouch of Douglas opened to allow ligation and division of the partial cardinal and uterosacral ligament, as in a traditional vaginal hysterectomy. All of the 101 cases in our study adhered to the following criteria: (1) no adnexal disease (2) no gynecologic surgery history. When a TVH was performed, if we encounter difficulty in removing the uterus during he operation, it was cut in half or crushed or we performed a myomectomy to decrease the solidity.2
All perioperative data were collected. Every patient was given a pain investigation sheet. Patients filled in the pain investigation sheet immediately, 45 minutes, 3 hours, 24 hours and 48 hours after operation using VAS visual pain score. Three cases of TAH and total TVH were performed under spinal anesthesia, 17 cases of TAH and total LAVH were performed under general anesthesia. Different anesthesias affect the results of pain score both immediately and 45 minutes after operation. Some patients used analgesics after the operation.
Results were evaluated by Linear regression analysis, Fisher's exact test and Student's t test for independent samples. All statistical analyses were performed using the SPSS 11.0 software. P <0.05 was considered statistically significant.
Among these 69 patients who underwent LAVH or TVH, none had to be converted to TAH during the procedure. No serious complication occurred in the peri-operative period in these three groups.
The intra-operative characteristics in three groups were shown in Table 1. There was no significant difference in the mean length of operating time in the three groups (P >0.05). This implied that no learning-curve phenomenon was observed among the 5 senior surgeons. The estimated amount of blood loss was similar in both the LAVH and TAH groups (P >0.05). Blood loss was less in the TVH group than in the other two groups (P <0.05). No blood transfusions were given to any patients during or after surgery. The cost of LAVH in China is 1733 Yuan (RMB), while the cost of the TAH and TVH procedure in China is the same, 920 Yuan (RMB).
Table 2 shows the pain score after operation in these three groups according to the different method in anesthesia, that can affect the pain score immediately and 45 minutes after the operation. Statistical analysis was not performed for these 2 periods. The pain score at 3 hours after operation in the LAVH group was less than in TAH group TVH groups (P <0.001). The pain scores at 24 hours and 48 hours after operation in the LAVH group and TVH group were less than in the TAH group (P <0.01).
Comparison of the outcome from the three types of hysterectomy is shown in Table 3. The average recovery time for the bowel in the LAVH group was 20.0 hours, versus 24.8 hours in the TVH group and 36.6 hours in the TAH group (P <0.05 in three groups). The patients in the LAVH and TVH groups were discharged much earlier than the patients in the TAH group (P <0.001). The average highest body temperature in the TAH group was much higher than what was measured in the LAVH or TVH group (P <0.001). Morbidity in the TAH group is 10% while no morbidity was recorded in the LAVH and TVH groups.
Traditionally, hysterectomy is performed abdominally. The disadvantage of abdominal hysterectomy is the prolonged recovery and the high incidence for abdominal adhesions. This may be due to the larger abdominal incision and the procedure of laparotomy itself. Since LAVH was described by Reich et al3 in 1989 and TVH has been shown not to be limited to treat a prolapsed uterus, these less-invasive techniques have become attractive options for conventional incision and manipulations of abdominal hysterectomy.
In the first stage, the operation duration is significantly longer in LAVH than in TAH.4,5 There was no significant change in the mean length of operating time for three groups in our study. And blood loss was less in TVH group than that of other two groups in our data. Lowell et al6 compare LAVH and TAH, they found the risk of transfusion and complication in the LAVH group is higher than in the TAH group. We did not observe this phenomenon in our randomizing study.
Our data also showed that the pain scores after 24 hours and 48 hours in the LAVH and TVH groups were less than in the TAH group (P <0.01). The average time to bowel recovery in the LAVH group was shortest and recovery time for the TVH group second shortest. The patients in the LAVH and TVH groups were discharged much earlier than patients in the TAH group (P <0.001). However, morbidity in the TAH group was higher.
Young et al7 reviewed 39 papers and found that the outcome of LAVH was not better than TAH. The perioperative findings of our study suggest the outcomes of LAVH and TVH are better than TAH. Other characteristics, excluding the pain score at 3 hours after the operation, show TVH is better, or at least equivalent to, LAVH. The advantage of the less invasive techniques, LAVH and TVH, is clear but it does not mean that they can always be substituted for TAH.
Our research suggests there is a shorter operation time, less blood loss, lower morbidity, less pain and a shorter recovery time in the TVH group. No incision and low cost are also a benefit. The decision as to whether or not TVH can be done can only be made after the surgeon considers the size of the uterus, mobility of uterus, nulliparity and volume of the vagina. When the uterine size is estimated preoperatively to be smaller than 14 gestational weeks and the weigh of the uterus is estimated preoperatively to be less than 600 g is it considered safe to proceed with a TVH.2 Contraindications of TVH are: pelvic inflammatory disease, endometriosis, suspected or confirmed malignant gynecologic disease, pelvic surgery history, adnexal disease, broad myoma or nulliparity.
The anatomical field of vision can be amplified during laparoscopic surgery. We can visualize the uterus more clearly and close the vaginal and rectum easily. Hemostasis can be accomplished and blood clots can be cleared easily. LAVH has a lower morbidity rate, less pain and a shorter recovery time than TAH. In this study, LAVH does not require a longer operation time and there is not much blood loss if LAVH is performed by experienced surgeons. The cost of LAVH is higher than TAH or TVH in China. Lowell et al6 found LAVH increased the need for blood transfusion and had more intra-operative complications. The indications for LAVH are for gynecologic benign diseases (such as endometriosis, adhesion and adnexal tumor) that are not fit for TVH. If an adnexal tumor is too big to remove completely from vaginal access or is too difficult to be totally fit into an endobag, especially for postmenopausal patients, LAVH is not recommended. Leakage of the tumor increases the risk for malignancy. In a retrospective study on 502 women, Dersey et al8 found that patients who underwent TAH were significantly older than those who underwent LAVH. Although LAVH can be safely performed in many elderly patients, the compromise of respiratory and circulatory function in some of these patients influences the preference choice of TVH, TAH or LAVH.
TAH is widely used for hysterectomy at present. If the size of the uterus is larger than 14 gestational weeks, there are serious pelvic adhesions or suspected malignancy, TAH is the best choice for hysterectomy because of the good view, a lower difficulty to operate and minimization of complications.
Recently, Abdelmonem et al9 reported a prospective observational comparison of abdominal, vaginal and laparoscopic hysterectomy as performed at a university teaching hospital. Operative time was shortest for TVH (103 minutes), followed by TAH (127 minutes), and longest for LH (157 minutes). Pain and recovery milestones were significantly lower for the LH and TVH groups when compared to the TAH group. The complication rates did not differ significantly between the groups. The results suggest that vaginal hysterectomy remains the most cost-effective approach. Our study is similar to other studies.10,11 Since China is a developing country with a shortage of medical resources, TVH should be generalized.
Multiple logistic regression analysis was applied to identify factors influencing the choice of hysterectomy on 390 patients by Shao et al.5 Two independent factors, surgeons’ expertise and the concomitant adnexal surgery, had a strong influence on the decision-making process. Although our study showed LAVH and TVH were safe and effective for women requiring hysterectomy, each different route for hysterectomy had its own advantage and disadvantage.
In conclusion, choices of different routes for hysterectomy depend on considering the combine disease, the patient's condition, the surgeons’ experiences and the medical equipment.
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