Laparoscopic-assisted vaginal hysterectomy versus minilaparotomy hysterectomy: a prospective, randomized, multicenter study

STUDY OBJECTIVE: The aim of this study was to compare operative and early postoperative outcomes of laparoscopic-assisted vaginal hysterectomy (LAVH) and minilaparotomy in a randomized clinical trial including patients undergoing total hysterectomy for benign gynecologic disease and having 1 or more of the generally considered contraindications to vaginal route. DESIGN: Prospective, randomized, multicenter trial (Canadian Task Force classification I). SETTING: Departments of Gynecology from 3 major university hospitals in Rome. PATIENTS: Eighty-one patients who were candidates for abdominal hysterectomy. INTERVENTIONS: Laparoscopic-assisted vaginal hysterectomy and minilaparotomy hysterectomy. MEASUREMENTS AND MAIN RESULTS: Forty patients were randomized to LAVH and 41 to minilaparotomy. Characteristics of patients and indications for surgery in the 2 arms were comparable. In the minilaparotomy group, complications were as follows: 1 case (2.4%) of delayed laparotomy with 2 units of red blood cell transfusion, 2 cases (4.8%) of wound infection, and 3 cases (7.3%) of fever of unknown origin. No minor or major complications were observed in the LAVH group. Postoperative visual analog scale pain scores at days 1 and 2 were significantly lower in the LAVH group (p <.05). The complication rate between the 2 groups was significantly lower for LAVH (p = .026). CONCLUSION: Because LAVH was associated with significantly lower early postoperative pain scores and complication rates, in general LAVH should be preferred to minilaparotomy hysterectomy when the vaginal approach cannot be used.     

Operative outcomes of single-port-access laparoscopy-assisted vaginal hysterectomy compared with single-port-access total laparoscopic hysterectomy

ObjectiveThis study aims to compare between operative outcomes of single-port-access laparoscopy-assisted vaginal hysterectomy (SPA-LAVH) and single-port-access total laparoscopic hysterectomy (SPA-TLH), further subdivided by vaginal cuff closure via laparoscopic suture (VCC-L) or via the vaginal route (VCC-V).Materials and methodsA custom-made port was used for single-port laparoscopy in 111 patients who underwent SPA-LAVH (n = 33), SPA-TLH with VCC-L (n = 35), and SPA-TLH with VCC-V (n = 43) during October 2009–October 2010. Records were reviewed retrospectively.ResultsA significant difference in the operating time was observed among the groups (p = 0.009). SPA-TLH with VCC-L took a significantly longer time to be performed (118.6 ± 41.8 minutes) than SPA-TLH with VCC-V (98.6 ± 21.3 minutes) or SPA-LAVH (102.0 ± 20.3 minutes). The decrease in hemoglobin level on the 1^st day postsurgery was significantly smaller in case of SPA-LAVH (1.56 ± 0.97 g/dL, p = 0.005) compared with that in case of SPA-TLH with VCC-L (2.19 ± 0.95 g/dL) and SPA-TLH with VCC-V (2.24 ± 0.95 g/dL). No significant differences in other surgical outcomes were found.ConclusionSPA-TLH with laparoscopic vaginal suture required the longest operating time, and hemoglobin changes were smaller in the SPA-LAVH group than in the other groups. In patients undergoing SPA laparoscopy, we recommend the SPA-LAVH procedure.     

Total laparoscopic hysterectomy versus vaginal hysterectomy: a prospective randomized trial

AIM: The aim of the study was to compare the effects of total laparoscopic hysterectomy with those of vaginal hysterectomy. METHODS: We conducted a prospective randomised trial on 400 patients who agreed to be randomized to either laparoscopic total hysterectomy or vaginal hysterectomy. They were monitored for one year to evaluate the rate of major complications and the results on quality of life. RESULTS: Total laparoscopic hysterectomy was associated with a higher rate of major haemorrhages and ureteric injuries than vaginal hysterectomy (7% vs 2.5% and 2.5% vs 0%; P<0.05) only during the first year of study according to a normal learning-curve. It took longer to perform (85.9 min vs 46.6 min), but was less painful (visual analogue scale 5.3 vs 6.0; P<0.01) and there was a shorter stay in hospital after the operation (2.9 vs 3.3 days). Six weeks after the operation, total laparoscopic hysterectomy was associated with less pain and better quality of life than vaginal hysterectomy (SF-12). CONCLUSION: Total laparoscopic hysterectomy was associated with a significantly higher rate of major haemorrhages and ureteric injuries than vaginal hysterectomy only during the first year of study according to a normal learning-curve. It took longer to perform but was associated with less pain, quicker recovery, and better short term quality of life.     

A prospective,randomized study of closed-suction drainage after laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To estimate whether closed-suction drainage of the pelvis after laparoscopic-assisted vaginal hysterectomy reduces the risk of postoperative morbidity. DESIGN: Prospective, randomized study (Canadian Task Force classification 1). SETTING: Teaching medical center. PATIENTS: Three hundred twenty-four women. INTERVENTION: Laparoscopic-assisted vaginal hysterectomy. MEASUREMENTS AND MAIN RESULTS: The 160 women in group 1 had closed-suction (Jackson-Pratt) drains inserted into the peritoneal cavity and cul-de-sac, whereas the 164 in group 2 had no drains. Postoperative time to flatulence, hemoglobin, analgesic requirements, duration of hospital stay, rehospitalization, complications, febrile morbidity, and infection were studied. No statistically significant differences were seen between groups in demographics, outcome measures, postoperative infectious morbidity, or complications. The small power value may mean that no true differences existed for most tests. A statistically significant difference in analgesic requirement was found, with more oral analgesics taken by women in group 2. CONCLUSION: Prophylactic surgical drainage may not be necessary to prevent postoperative morbidity after laparoscopic-assisted vaginal hysterectomy when prophylactic and postoperative antibiotics are given. A drain still has its role in gynecologic laparoscopy in selected women, such as in those with persistent ooze from raw surfaces, bowel injury, or frank pus in the abdomen.     

A prospective randomized comparison of vaginal hysterectomy,laparoscopically assisted vaginal hysterectomy,and total laparoscopic hysterectomy in women with benign uterine disease

Objectives

To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).

Study design

A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.

Results

Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.

Conclusions

Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.     

Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting.

OBJECTIVE: To compare outpatient laparoscopy-assisted vaginal hysterectomy with standard outpatient vaginal hysterectomy. METHODS: Fifty-six women scheduled for vaginal hysterectomy were randomly assigned to undergo either a laparoscopy-assisted vaginal hysterectomy with endoscopic staples (N = 29) or a standard vaginal hysterectomy (N = 27). There were no differences between the study groups with regard to age, gravidity, parity, preoperative indications, and previous operations. RESULTS: Twenty-eight of 29 laparoscopy-assisted vaginal hysterectomies and all 27 vaginal hysterectomies were completed without incident. When indicated, unilateral or bilateral oophorectomies were completed. The mean operating time was significantly longer for laparoscopy-assisted vaginal hysterectomy (120.1 versus 64.7 minutes). Fifty-three of the 55 patients completing surgery were discharged home by 12 hours from the time of admission. Complications with laparoscopic hysterectomy were related to the technical aspects of laparoscopy. The incidence of febrile morbidity was similar in the groups. Although patients having laparoscopy-assisted hysterectomy required statistically significantly more pain medication and had lower postoperative hematocrit measurements, this did not make a clinical difference in the postoperative courses. The mean hospital charge for laparoscopy-assisted vaginal hysterectomy was $7905 and for vaginal hysterectomy $4891. CONCLUSION: Other than cost, laparoscopy-assisted vaginal hysterectomy and standard vaginal hysterectomy appear comparable in patients who could otherwise undergo a vaginal hysterectomy.     

Laparoscopic supracervical hysterectomy versus laparoscopic total hysterectomy: a prospective randomized study

AIM: The aim of this study was to compare surgical complications and clinical outcomes after supracervical versus total laparoscopic hysterectomy for the control of abnormal uterine bleeding or symptomatic uterine leiomyomata. METHODS: We conducted a prospective randomized trial on 141 patients who had laparoscopic hysterectomy for symptomatic uterine leiomyomata, abnormal bleeding refractory to hormonal treatment, or both. Patients were randomly assigned to receive a supracervical or total laparoscopic hysterectomy. We compared surgical complications and clinical outcomes for 2 years after randomization. RESULTS: Seventy-one participants were assigned to supracervical laparoscopic hysterectomy (SLH) and 70 to total laparoscopic hysterectomy (TLH). Hysterectomy by either techniques led to statistically significant reductions in most symptoms, including pelvic pain or pressure, back pain and urinary incontinence. Patients assigned to SLH tended to have more hospital readmissions than those randomized to TLH. There were no statistically significant differences in the rate of complications, degree of symptoms improvement, or activity limitation. Participants weighing more than 100 kg at study entry were more than twice as likely to be readmitted to the hospital during the 2-year of follow-up (OR 2.48, 95% CI 0.11; 1.91, P=0.04). CONCLUSIONS: We did not observe statistically significant differences between SLH and TLH in surgical complications and clinical outcomes during the 2-years of follow-up.     

Comparison between bisection/morcellation and myometrial coring for reducing large uteri during vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy: results of a randomized prospective study

BACKGROUND: Vaginal hysterectomy (VH) is being performed increasingly by gynecologic surgeons. Thus, enlarged uteri are more frequently removed vaginally, requiring reducing techniques to allow vaginal extraction. MATERIAL AND METHODS: We designed a randomized prospective study to compare bisection-morcellation and myometrial coring. Patients scheduled for VH or laparoscopically assisted vaginal hysterectomy (LAVH) were offered entry into the study. Endometrial cancer was an exclusion criterion. Uterine size was not a contraindication for vaginal surgery. We compared data from preoperative workup as well as from the operative and the postoperative course. Data were recorded prospectively. Results were analyzed with nonparametric tests and logistic regression models. RESULTS: Thirty patients were included in the study. Patients were similar in both groups. No severe peroperative complication occurred in this series. Operating time was comparable in both groups. Uteri weighed more than 280 g in more than 70% of patients in both groups. Myometrial coring failed more often than bisection-morcellation (25% vs. 0%, p = 0.06). Patients and uteri characteristics had no influence on the risk of failure, except for narrow uteri, which were associated with an increased risk of failure in the myometrial coring group only (68.3 vs. 83.9 mm, p = 0.01). Postoperative courses were similar for the two techniques, except for an increased rate of fever in the myometrial coring group (28%, p = 0.03). CONCLUSION: Both techniques appeared safe in this trial. Myometrial coring failed more frequently than bisection-morcellation, especially in the case of a narrow uterus. Postoperative fever was significantly more common after myometrial coring. Both techniques should be taught to resident surgeons.     

Misoprostol vaginal insert compared with dinoprostone vaginal insert: a randomized controlled trial

OBJECTIVE: To compare the 50-microgram (misoprostol vaginal insert 50) and 100-microgram (misoprostol vaginal insert 100) dose reservoirs of the misoprostol vaginal insert to 10-mg dinoprostone vaginal insert for time to vaginal delivery and rate of cesarean delivery. METHODS: A total of 1,308 women requiring cervical ripening (modified Bishop score less than or equal to 4) before induction of labor were randomly assigned to receive misoprostol vaginal insert 100 (n=428), misoprostol vaginal insert 50 (n=443) or 10-mg dinoprostone vaginal insert (n=436). The primary outcomes were time to vaginal delivery and rate of cesarean births. Safety was also assessed by comparing frequency of adverse events. RESULTS: Median time to vaginal delivery was 1,596, 2,127, and 1,650 minutes for misoprostol vaginal insert 100, misoprostol vaginal insert 50, and dinoprostone vaginal insert, respectively (P=.97 and 0.01 compared with dinoprostone vaginal insert, respectively). Of those who delivered in first admission, cesarean deliveries occurred in 119 of 421 (28.3%), 124 of 429 (28.9%), and 115 of 424 (27.1%) of participants treated with misoprostol vaginal insert 100, misoprostol vaginal insert 50, and dinoprostone vaginal inserts, respectively (relative risk 1.04, 95% confidence interval 0.84-1.30 for misoprostol vaginal insert 100 and relative risk 1.06, 95% confidence interval 0.86-1.32 for misoprostol vaginal insert 50 compared with dinoprostone vaginal insert). Medication-related adverse events included hyperstimulation syndrome in 17 of 428 (4.0%), 6 of 443 (1.4%), and 21 of 436 (4.8%); and nonreassuring fetal heart rate patterns in 63 of 428 (14.7%), 54 of 443 (12.2%), and 67 of 436 (15.4%) of participants treated with the misoprostol vaginal insert 100, misoprostol vaginal insert 50, and dinoprostone vaginal inserts, respectively. CONCLUSION: The misoprostol vaginal insert 100 and the dinoprostone vaginal insert had similar median time intervals to vaginal delivery, whereas the misoprostol vaginal insert 50 had a significantly longer time to vaginal delivery. The three products had similar cesarean rates and safety profiles.     

Ureter injury during laparoscopy-assisted vaginal hysterectomy with the endoscopic linear stapler.

Ureter injury is more common with abdominal hysterectomy than vaginal hysterectomy. Complications during laparoscopy-assisted vaginal hysterectomy cases have not been thoroughly studied. Two cases are presented that highlight urologic misadventures, specifically, ureteral injury, with the endoscopic linear stapler during laparoscopy-assisted vaginal hysterectomy.