Comparison of vaginal hysterectomy and laparoscopic hysterectomy: a systematic review and meta-analysis

A substantial number of women undergo hysterectomy annually, and 70 % of hysterectomies are performed for benign indications, including leiomyoma, adenomyosis, severe dysmenorrhea and uterine prolapse [1]. The surgical approach of hysterectomy is the most important factor responsible for postoperative morbidity. Until the present, the approaches for hysterectomies are vaginal, abdominal, laparoscopic and robotic assisted laparoscopic hysterectomy. If feasible, vaginal hysterectomy is associated with a shorter duration of hospital stay, speedier recuperation, fewer unspecified infections or febrile episodes than abdominal hysterectomy [2]. Since Reich first performed laparoscopic hysterectomy (LH) in 1989, various laparoscopic techniques and instruments have been developed, resulting in the vigorous implementation of LH, including laparoscopic-assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH) at present [3]. In contrast, VH is commonly utilized to treat uterine prolapse, but despite proven safety and effectiveness, it remains underutilized for the surgical treatment of non-prolapse conditions [4]. Gynaecologists perform LAVH or TLH according to their preference, and it is conservative to say that gynaecologists performing LH almost never perform VH [4]. There are several reasons for the widespread implementation of LH. First, LH can facilitate a better anatomical view, which has advantages over VH in cases of severe endometriosis or when there is a history of pelvic inflammatory disease. Second, in cases of large uterine size and for uteruses with little or no descent, LH simplifies the separation of the uterus from its attachment to the pelvic wall [5]. There are multiple approaches to hysterectomy, and each method has its procedure-specific advantages and disadvantages. Since VH and LH are minimally invasive techniques for benign indications that are widely performed around the world, we present a meta-analysis of randomised controlled trials (RCTs) comparing LH with VH for benign gynaecological conditions to identify which surgical approach is superior with respect to various surgical outcomes, especially the rates of complications.

The primary search retrieved 1611 citations with combinations of the terms “hysterectomy”, “laparoscop*”, “vagina*”, “laparoscop* AND assisted AND vagina*” and “benign AND condition* OR indication* OR disease* OR disorder*”, which were screened for eligible studies. After excluding duplicate citations, 1041 potentially eligible citations were identified and examined in detail. Of these, 1023 articles were excluded because of the inclusion of only one surgical approach (VH or TLH or LAVH), non-RCT design or inclusion of patients with malignancies. Eighteen articles reporting results from RCTs comparing VH (n = 677) with LH (n = 941) were included in the present meta-analysis (Fig. 1). The meta-analysis was performed using Review Manager, and the studies comparing VH and LH were divided into three subgroups: VH vs. LAVH; VH vs. TLH; and VH vs. unspecified LH. Hence, the number of studies on VH was duplicated in each outcome. The risks of bias in the included studies are summarised in Fig. 2.

The surgical approach of hysterectomy is the most important factor responsible for postoperative morbidity. Many studies have compared the surgical approach and complications according to the type of surgery to determine which method is best for the patient. The conclusion suggests that abdominal hysterectomy is inferior to VH and LH [32]. There were few randomized trials comparing VH and LH for postoperative complications, operative time, hospital stay, and recovery. The results of our meta-analysis showed no difference between the two groups for the overall rate of complications, including grade I, II and III complications of intraoperative blood loss, intraoperative conversion, length of hospital stay and length of recuperation after surgery. VH was associated with a shorter operative time and less pain at 24 h after surgery than LH. An important matter of concern about LH is a higher incidence of urinary tract injuries [33]. Our meta-analysis showed no significant difference in urinary tract injuries between VH and LH (10 of 887 vs. 10 of 1055; p = 0.68). A recent study of 839 women undergoing hysterectomy for benign indications reported that the incidence of urinary tract injuries was 4.3%, including an incidence of 2.9% for bladder injury and 1.8% for ureteral injury [34]. One review article reported that the incidence of ureteral injury is estimated to be 0.03 to 2% for AH, 0.02 to 0.5% for VH and 0.2 to 6% for LH [35]. In this meta-analysis, we found that the incidence of urinary tract injuries was 1.02%. Hence, the incidence of ureteral injury was unlikely to be underreported in the included studies. Interestingly, we found two fistula formations following TLH but no fistula formations following VH. During TLH, many surgeons use electrical laparoscopic instruments to cauterize the uterine artery and dissect the vesicouterine fold; the incidence of fistula formation might thus increase as a consequence of thermal injury [36]. A Cochrane review in 2015 concluded that VH appears to be superior to LH for benign indications, as VH is associated with a faster return to normal activities than LH according to a meta-analysis including two studies of 140 patients [14, 17], and there were no advantages of LH over VH, as the operation time was longer for LH and the incidence of urinary tract injuries was greater for TLH than for VH [32]. Comparing our meta-analysis including four additional RCTs with 440 patients (VH vs. LH) to Cochrane review in 2015, the operation time of VH was significantly faster than that of LH similarly but we found no difference between the two groups in the time to return to normal activities, incidence of urinary tract injury and length of hospital stay. Furthermore, VH was associated with reduced pain scores at 24 h after surgery. The more postoperative pain in LAVH in our study might be caused by the pneumoperitoneum, the pain caused by traction of uterus and the abdominal incisions for the ports [24]. One study concluded that LH was the least cost-effective due to the expensive laparoscopic devices and long operation time [37]. The operation time of LH has shortened over the last couple decades. However, the cost of disposable laparoscopic devices is inevitably more expensive than that of the conventional surgical instruments used in VH.

Gynaecologists around the world should focus on the effect of the rapid development of LH on the treatment of benign indications, especially VH training and skills among residents. When deciding the route of hysterectomy, the preference and proficiency of the surgeon may be the most decisive factors. As a result, if LH is performed more often than VH, gynaecologists in the future will be unfamiliar with VH, leading to a more profound decrease in the implementation of VH. Despite evidence supporting benefits of VH, current statistics indicate VH is underutilised in treating benign gynaecologic conditions [4]. The decreased utilisation of VH is undesirable because VH is the least invasive approach, shorter operating time and less cost than other types of hysterectomy from an evidence-based viewpoint. Main causes associated with decreased utilisation of VH include changes of resident training in surgical techniques due to the tremendous developments of laparoscopic skills and devices, changes of surgical skills in practice, attention to alternative hysterectomy techniques, and enormous propaganda effects of laparoscopic device companies. To increase the rate of VH as the primary approach in possible cases, teaching hospitals around the world should try to increase utilisation of VH on purpose for increasing familiarity with VH during resident training.

According to our review, if both procedures are technically feasible, VH exhibits advantages in the operating time, which can be one of the most important factors for reducing hospital cost. All of hysterectomy cannot be performed by VH, but all of hysterectomy should not be performed laparoscopically.

The limitation of our study is that all included studies had a high risk of bias in blinding despite the RCT design. Hence, no outcome had high-quality evidence according to the GRADE methodology. However, given that our primary outcome was the comparison of complication risk between the two groups, outcomes such as overall complications, grade 3 complications and risk of urinary tract injuries had moderate-quality evidence. Additional large-scale, multicenter, long-term randomized trials including objective outcome assessment will be required to definitively establish the value of LH vs VH.

The results of this study suggest that VH should be the treatment of benign gynecologic disease when both operative methods are available. Large randomized controlled trials should be performed to identify differences in VH and LH outcomes for operation time, postoperative pain, perioperative complications and cost.