Do the Different Approaches Stem from Real Medical Advantages or Surgeon Preferences?
T. Falcone
Department of Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
In spite of the trend toward alternatives to hysterectomy, it remains one of the most frequent surgical procedures performed in the United States. New laparoscopic techniques have been heralded as important treatments that will decrease both the morbidity and the cost of hysterectomy. It is therefore imperative that prospective randomized studies be conducted to evaluate these new techniques.
The main bias of surgical studies is attributed to the nonmasked nature of the study. Even with standard protocols, it is difficult to eliminate the traditions that are part of a surgical practice, as well as the expectations of patients. The major criticisms of previous trials are that most of the hysterectomies could be managed by the more cost effective vaginal route and that postoperative recovery variables, such as hospital length of stay, are more a comparison of traditional surgical practice than precise outcomes. In our institution most hysterectomies (66.5%) for nonmalignant disease are performed vaginally. Postoperative length of hospital stay and convalescence are often determined by factors other than the type of surgery, such as surgical tradition, insurance company policy, and patient expectations. The hospital length of stay in many centers outside the United States is not the standard of care here. In the European studies the hospital length of stay for abdominal hysterectomy ranged from 5 to 6 days,1,2,3 whereas the median length of stay for abdominal hysterectomies is our center is 2.5 days. Other comparative trials of laparoscopy versus laparotomy often report hospital stays longer than the standard for the USA. A longer hospital stay for surgical procedures performed by laparotomy, such as ectopic pregnancies (4.5 days),4 removal of ovarian cysts (3.8 days),5 and Burch procedures (11.2 days)6 will overestimate the advantage of laparoscopic surgery. These differences illustrate the arbitrary nature of this outcome in most studies. These differences are especially important in cost effectiveness studies, where the decrease in hospital stay is the principal reason for the decrease in overall hospital cost for a laparoscopic procedure. In our study we showed that when strict criteria are used the hospital stay of a laparotomy procedure can be decreased. However, a laparoscopically assisted vaginal hysterectomy was still associated with a shorter hospital course. The following is the result of our randomized clinical trial.
Objective
We compared operative time, length of hospital stay, postoperative recovery, return to work, and costs for women undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy.
Study Design
A prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy (n=24) versus abdominal hysterectomy (n=24) was carried out in a tertiary care setting. The main outcome variables were operative time, length of hospital stay, and return to work. Secondary outcomes were postoperative pain and return to normal activity as determined by weekly visual analog scales and daily diary. Hospital costs were calculated.
Results
The laparoscopically assisted vaginal hysterectomy group had longer operative times (median and quartiles, laparoscopically assisted vaginal hysterectomy 180[139,225] minutes vs. abdominal hysterectomy 130 [97,155] minutes), lower requirements for postoperative intravenous analgesia (patient-controlled analgesia pump, median and quartiles: laparoscopically assisted vaginal hysterectomy 22.1 [15.9,23.5] hours, abdominal hysterectomy 36.7 [26.2,45.0] hours), shorter length of hospital stay (median and quartiles, laparoscopically assisted vaginal hysterectomy 1.5 [1.0,2.3] days, abdominal hysterectomy 2.5 [1.5,2.5] days), and quicker return to work (Kaplan-Meier analysis, P=.03). Both procedures had similar hospital costs(P=.21).
Conclusion
Laparoscopically assisted vaginal hysterectomy appears to allow patients a more rapid postoperative recovery and an earlier return to work with hospital costs similar to those of abdominal hysterectomy. (Am J Obstet Gynecol 1999;180:955-62.)7 References
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3. Phipps JH, John M, Nayak S. Comparison of laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy with conventional abdominal hysterectomy and bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 1993;100:698-700.
4. Saxon D, Falcone T, Mascha EJ, Marino T, Yao M, Tulandi T. A study of ruptured tubal ectopic pregnancies. Obstet Gynecol 1997;90:46-9.
5. Lin P, Falcone T, Tulandi T. Excision of ovarian dermoid cyst by laparoscopy and by laparotomy. Am J Obstet Gynecol 1995;173:76971.
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7. Falcone T, Paraiso MF, Mascha E. Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy. Am J Obstet Gynecol 1999;180:955-62.