Cochrane Review Favors Vaginal Hysterectomy : The vaginal approach meant shorter hospital stays and quicker return to normal activities.

David Barlow, M.D., a coinvestigator of the Cochrane review and executive dean of medicine at the University of Glasgow in Scotland, said that most surgeons in the United Kingdom, who are paid the same regardless of which approach is employed, perform abdominal hysterectomies and that “few” surgeons are specially trained in laparoscopic approaches.

The risk of urinary tract injury during laparoscopic operations was “not surprising” and, although it was statistically significant, “it was not that high.” Dr. Barlow added, that these findings need to be conclusively proven through more study and trial data.

It's also still unclear whether total laparoscopic hysterectomy has any benefits or harms over other forms of laparoscopic hysterectomy, he and his coinvestigators said in the review.

Data on long-term outcomes were “sparse” in the trials that were included in the review, said Dr. Barlow and Dr. Johns and their colleagues in the review.

Future trials should report on outcomes such as long-term urinary, bowel, and sexual function, as well as the occurrence of fistulae, they added.

Dr. Stovall, clinical professor of obstetrics and gynecology at the University of Tennessee in Memphis, said that interpreting the review is difficult because trials to date have not set and adequately controlled for indications and criteria for various approaches to hysterectomy.

“It all comes down to the issue of patient selection, indications, and inclusion and exclusion criteria” for particular approaches, he said.

“These are somewhat subjective decisions” in clinical practice, but ideally, investigators would control for these factors in future trials, Dr. Stovall added.

With long-term follow-up, “I don't think we'll see any difference in outcomes for one approach versus another.”

Dr. Barlow emphasized, however, the importance of short-term patient recovery.

“What this paper is saying—a main message—is that patients are home a day earlier on average [with vaginal hysterectomy] and return to normal quicker. Patients like speedier recoveries,” he said.

In this preoperative view, the uterus and ovaries are completely encased in adhesions from prior surgeries; only the fundus and anterior uterus are visible.

Using laparoscopic techniques, the uterus and ovaries have been dissected free, allowing the uterus to be removed vaginally.

The laparoscopic-assisted vaginal hysterectomy has been completed, and the ovaries have been left in place. Photos courtesy Dr. Alan Johns