Cochrane Clinical Answers - Fulltext - In women with benign gynecological disease, how do different approaches to hysterectomy compare at improving outcomes?

Question:In women with benign gynecological disease, how do different approaches to hysterectomy compare at improving outcomes?

Clinical Answer:

Vaginal hysterectomy seems to provide better outcomes compared with abdominal or laparoscopic hysterectomy, but not enough data are available to reach conclusions about other comparisons.

When vaginal hysterectomy was compared with abdominal hysterectomy, moderate-quality evidence showed a shorter time to return to normal activities with vaginal hysterectomy (on average by 12 days) and length of hospital stay (on average by 1 day), with similar rates of intraoperative visceral injury with the two approaches. Fewer women undergoing vaginal hysterectomy experienced wound/abdominal wall infection compared with abdominal hysterectomy (on average 11 versus 50 per 1000 women).

Low-quality evidence suggested a shorter return to normal activities with laparoscopic hysterectomy compared with abdominal hysterectomy (by an average of 8 to 15 days depending on the laparoscopic procedure used), but higher risk of urinary tract injury (on average 24 versus 10 per 1000 women). Moderate-quality evidence showed similar rates of bowel and vascular injury between groups. Wound/abdominal wall infection and febrile episodes were less common with laparoscopy (with an average of 29 to 88 fewer women experiencing these outcomes per 1000) but trials evaluating other short and long-term complications were too small to provide meaningful results.

Moderate to low-quality evidence suggested similar rates in urinary and vascular injuries, complications and return to normal activities when comparing laparoscopic hysterectomy with vaginal hysterectomy. However, most of the analyses were not sufficiently powered to detect differences between groups if these were present.

Not enough data were available comparing robot-assisted hysterectomy with laparoscopic hysterectomy to make a statement.

Full outcome data is detailed below:

1.Vaginal hysterectomy versus abdominal hysterectomy

  • Population, Intervention, Comparator

    Population:

    Women (age range 38 to 55 years) who needed a hysterectomy for benign causes (mostly abnormal uterine bleeding, endometriosis, prolapse or uterine fibroids)

    Intervention:

    Vaginal hysterectomy (VH)

    Comparator:

    Abdominal hysterectomy (AH): standard abdominal hysterectomy or minilaparotomy

  • OUTCOME 1.1: Return to normal activities

    Quality of the evidence:

    The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was moderate quality. See Summary of findings from Cochrane review

    Narrative result:

    Three RCTs with 176 participants found that women undergoing VH had a shorter return to normal activities compared with AH.

    Relative effect or mean difference:

    There was a statistically significant difference between groups, in favor of VH (mean difference -12.33 days, 95% CI -19.89 to -4.77).

    Forest plot from Cochrane Review

    Reference:
    Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
    • OUTCOME 1.2: Satisfaction

      Risk of bias of studies:

      The reviewers did not perform a GRADE assessment of the quality of the evidence. The study failed to report adequate allocation concealment, did not report adequate blinding of outcome assessors and had low numbers of withdrawals.

      Narrative result:

      One RCT with 119 participants found no statistically significant difference between groups, but the study would have been underpowered.

      Relative effect or mean difference:

      There was no statistically significant difference between groups (OR 2.69, 95% CI 0.50 to 14.42).

      Forest plot from Cochrane Review

      Absolute effect:

      967 per 1000 women (95% CI 844 to 994) with VH compared with 915 per 1000 women with AH.

      Reference:
      Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
      • OUTCOME 1.3: Intraoperative visceral injury - [Urinary tract (bladder or ureter) injury]

        Quality of the evidence:

        The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was moderate quality. See Summary of findings from Cochrane review

        Narrative result:

        Four RCTs with 439 participants found no statistically significant difference between groups, but the analysis would have been underpowered.

        Relative effect or mean difference:

        There was no statistically significant difference between groups (OR 3.09, 95% CI 0.48 to 19.97).

        Forest plot from Cochrane Review

        Absolute effect:

        We could not calculate absolute effects because of low events rate.

        Reference:
        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
        • OUTCOME 1.4: Long-term complications - [Urinary dysfunction]

          Risk of bias of studies:

          The reviewers did not perform a GRADE assessment of the quality of the evidence. The study reported adequate allocation concealment, did not report adequate blinding of outcome assessors and had low numbers of withdrawals.

          Narrative result:

          One RCT with 80 participants found no events.

          Reference:
          Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
          • OUTCOME 1.5: Short-term complications

            Narrative result:

            The following outcomes showed similar rates in both groups: transfusion, pelvic hematoma, vaginal cuff infection, urinary tract infection, chest infection and febrile episodes and there were no thromboembolism events in either group; however, some of the analyses would have been underpowered. Fewer women undergoing VH experienced wound/abdominal wall infection compared with AH. Click below for full details.

            Reference:
            Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
            • Subgroup analysis 1.5.1: Short-term complications - [subgroup: Wound/abdominal wall infection]
              Risk of bias of studies:

              The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 1/3 (33%) of the studies failed to report adequate allocation concealment, 2/3 (66%) did not report adequate blinding of outcome assessors and 1/3 (33%) had unclear numbers of withdrawals.

              Narrative result:

              Three RCTs with 355 participants found that fewer women undergoing VH experienced wound/abdominal wall infection compared with AH.

              Relative effect or mean difference:

              There was a statistically significant difference between groups, in favor of VH (OR 0.21, 95% CI 0.04 to 1.00).

              Forest plot from Cochrane Review

              Absolute effect:

              11 per 1000 women (95% CI 2 to 50) with VH compared with 50 per 1000 women with AH.

              Reference:
              Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
          • OUTCOME 1.6: Length of hospital stay

            Narrative result:

            Length of hospital stay was shorter in women undergoing VH compared with both standard hysterectomy and minilaparotomy abdominal hysterectomy. Click below for full details.

            Reference:
            Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
            • Subgroup analysis 1.6.1: Length of hospital stay - [subgroup: VH versus standard AH]
              Risk of bias of studies:

              The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 2/4 (50%) of the studies failed to report adequate allocation concealment, 3/4 (75%) did not report adequate blinding of outcome assessors and 1/4 (25%) had unclear numbers of withdrawals.

              Narrative result:

              Four RCTs with 295 participants found that women undergoing VH had shorter length of hospital stay compared with AH.

              Relative effect or mean difference:

              There was a statistically significant difference between groups, in favor of VH (mean difference -1.07 days, 95% CI -1.22 to -0.92).

              Forest plot from Cochrane Review

              Reference:
              Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
            • Subgroup analysis 1.6.2: Length of hospital stay - [subgroup: VH versus minilaparotomy AH]
              Risk of bias of studies:

              The reviewers did not perform a GRADE assessment of the quality of the evidence. The study reported adequate allocation concealment, did not report adequate blinding of outcome assessors and had unclear numbers of withdrawals.

              Narrative result:

              One RCT with 100 participants found that women undergoing VH had shorter length of hospital stay compared with AH.

              Relative effect or mean difference:

              There was a statistically significant difference between groups, in favor of VH (mean difference -2.10 days, 95% CI -2.19 to -2.01).

              Forest plot from Cochrane Review

              Reference:
              Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
          • OUTCOME 1.7: Bowel and vascular injury, Other short-term complications, Other major long-term complications

            Narrative result:

            The reviewers found no studies assessing these outcomes.

            Reference:
            Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]

            2.Laparoscopic hysterectomy versus abdominal hysterectomy

            • Population, Intervention, Comparator

              Population:

              Women (age range 38 to 55 years) who needed a hysterectomy for benign causes

              Intervention:

              Laparoscopic hysterectomy (LH): laparoscopic-assisted vaginal hysterectomy (LAVH), where part of the hysterectomy is performed by laparoscopic surgery and part vaginally, laparoscopic hysterectomy (LH(a)), where the uterine vessels are ligated laparoscopically but part of the operation is performed vaginally, LH with bilateral salpingo-oophorectomy (LH-BSO) or total LH

              Comparator:

              Abdominal hysterectomy (AH): AH with bilateral salpingo-oophorectomy or minilaparotomy

            • OUTCOME 2.1: Return to normal activities

              Narrative result:

              This outcome was reported separately by type of LH (LAVH or (LH(a)), where the uterine vessels are ligated laparoscopically but part of the operation is performed vaginally. In both cases, return to normal activities was quicker in women undergoing laparoscopic hysterectomy compared with abdominal one. Click below for full details.

              Reference:
              Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
              • Subgroup analysis 2.1.1: Return to normal activities - [subgroup: LAVH versus AH]
                Quality of the evidence:

                The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was low quality. See Summary of findings from Cochrane review

                Narrative result:

                One RCT with 80 participants found that women undergoing LH returned earlier to normal activities compared with AH.

                Relative effect or mean difference:

                There was a statistically significant difference between groups, in favor of LH (mean difference -8.40 days, 95% CI -12.15 to -4.65).

                Forest plot from Cochrane Review

                Reference:
                Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
              • Subgroup analysis 2.1.2: Return to normal activities - [subgroup: LH(a) versus AH]
                Quality of the evidence:

                The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was low quality. See Summary of findings from Cochrane review

                Narrative result:

                Five RCTs with 440 participants found that women undergoing LH returned to normal activities earlier than women undergoing AH.

                Relative effect or mean difference:

                There was a statistically significant difference between groups, in favor of LH (mean difference -15.17 days, 95% CI -17.21 to -13.14).

                Forest plot from Cochrane Review

                Reference:
                Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
            • OUTCOME 2.2: Satisfaction

              Risk of bias of studies:

              The reviewers did not perform a GRADE assessment of the quality of the evidence. The study reported adequate allocation concealment, did not report adequate blinding of outcome assessors and had high numbers of withdrawals.

              Narrative result:

              One RCT with 166 participants found no statistically significant difference between groups.

              Relative effect or mean difference:

              There was no statistically significant difference between groups (OR 0.65, 95% CI 0.32 to 1.30).

              Forest plot from Cochrane Review

              Absolute effect:

              694 per 1000 women (95% CI 530 to 820) with LH compared with 778 per 1000 women with AH.

              Reference:
              Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
              • OUTCOME 2.3: Urinary tract (bladder or ureter) injury

                Quality of the evidence:

                The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was low quality. See Summary of findings from Cochrane review

                Narrative result:

                13 RCTs with 2140 participants found that women undergoing LH had higher rates of urinary tract (bladder or ureter) injury compared with AH. Subgroup analyses by type of LH were too underpowered to provide meaningful results.

                Relative effect or mean difference:

                There was a statistically significant difference between groups, in favor of AH (OR 2.44, 95% CI 1.24 to 4.80).

                Forest plot from Cochrane Review

                Absolute effect:

                24 per 1000 women (95% CI 12 to 46) with LH compared with 10 per 1000 women with AH.

                Reference:
                Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                • OUTCOME 2.4: Bowel injury

                  Quality of the evidence:

                  The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was moderate quality. See Summary of findings from Cochrane review

                  Narrative result:

                  Four RCTs with 1175 participants found no statistically significant difference between groups. Subgroup analyses by type of LH were too underpowered to provide meaningful results.

                  Relative effect or mean difference:

                  There was no statistically significant difference between groups (OR 0.21, 95% CI 0.03 to 1.33).

                  Forest plot from Cochrane Review

                  Absolute effect:

                  1 per 1000 women (95% CI 0 to 11) with LH compared with 7 per 1000 women with AH.

                  Reference:
                  Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                  • OUTCOME 2.5: Vascular injury

                    Quality of the evidence:

                    The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was moderate quality. See Summary of findings from Cochrane review

                    Narrative result:

                    Two RCTs with 956 participants found no statistically significant difference between groups. Subgroup analyses by type of LH were too underpowered to provide meaningful results.

                    Relative effect or mean difference:

                    There was no statistically significant difference between groups (OR 1.76, 95% CI 0.52 to 5.87).

                    Forest plot from Cochrane Review

                    Absolute effect:

                    16 per 1000 women (95% CI 5 to 51) with LH compared with 9 per 1000 women with AH.

                    Reference:
                    Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                    • OUTCOME 2.6: Long-term complications

                      Narrative result:

                      Rates of fistula and urinary dysfunction were similar in both groups, but both analyses were underpowered. Click below for full details.

                      Reference:
                      Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                      • Subgroup analysis 2.6.1: Long-term complications - [Subgroup: Fistula]
                        Risk of bias of studies:

                        The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 1/2 (50%) of the studies failed to report adequate allocation concealment, neither reported adequate blinding of outcome assessors and 1/2 (50%) had unclear numbers of withdrawals.

                        Narrative result:

                        Two RCTs with 245 participants found no statistically significant difference between groups.

                        Relative effect or mean difference:

                        There was no statistically significant difference between groups (OR 3.07, 95% CI 0.32 to 29.96).

                        Forest plot from Cochrane Review

                        Absolute effect:

                        We could not calculate absolute effects because of low events rate.

                        Reference:
                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                    • OUTCOME 2.7: Short-term complications

                      Narrative result:

                      The following outcomes showed similar rates in both groups: transfusion, pelvic hematoma, unintended laparotomy, vaginal cuff infection, urinary tract infection, chest infection, thromboembolism and wound dehiscence but wound/abdominal wall infection and febrile episodes were less common with LH (although only with LAVH or LH(a)) than with AH. Some of the analyses were underpowered. Click below for full details.

                      • Subgroup analysis 2.7.1: Short-term complications - [Subgroup: Wound/abdominal wall infection]
                        Risk of bias of studies:

                        The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 1/6 (17%) of the studies failed to report adequate allocation concealment and/or random sequence generation processes, neither reported adequate blinding of participants/carers/outcome assessors and 1/6 (17%) had high numbers of withdrawals.

                        Narrative result:

                        Six RCTs with 611 participants found that fewer women undergoing LH experienced wound/abdominal wall infection compared with AH.

                        Relative effect or mean difference:

                        There was a statistically significant difference between groups, in favor of LH (OR 0.29, 95% CI 0.12 to 0.71).

                        Forest plot from Cochrane Review

                        Absolute effect:

                        13 per 1000 women (95% CI 5 to 30) with LH compared with 42 per 1000 women with AH.

                        Reference:
                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                      • Subgroup analysis 2.7.2: Febrile episodes or unspecified infection - [subgroup: LAVH versus AH]
                        Risk of bias of studies:

                        The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 1/4 (25%) of the studies failed to report adequate allocation concealment, none reported adequate blinding outcome assessors and all had low numbers of withdrawals.

                        Narrative result:

                        Four RCTs with 339 participants found that fewer women undergoing LH experienced febrile episodes or unspecified infection compared with AH.

                        Relative effect or mean difference:

                        There was a statistically significant difference between groups, in favor of LH (OR 0.25, 95% CI 0.09 to 0.73).

                        Forest plot from Cochrane Review

                        Absolute effect:

                        33 per 1000 women (95% CI 12 to 91) with LH compared with 121 per 1000 women with AH.

                        Reference:
                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                      • Subgroup analysis 2.7.3: Febrile episodes or unspecified infection - [subgroup: LH(a) versus AH]
                        Risk of bias of studies:

                        The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 4/7 (57%) of the studies failed to report adequate allocation concealment, none reported adequate blinding of outcome assessors and 3/7 (43%) had unclear numbers of withdrawals.

                        Narrative result:

                        Seven RCTs with 572 participants found that fewer women undergoing LH experienced febrile episodes or unspecified infection compared with AH.

                        Relative effect or mean difference:

                        There was a statistically significant difference between groups, in favor of LH (OR 0.55, 95% CI 0.33 to 0.90).

                        Forest plot from Cochrane Review

                        Absolute effect:

                        64 per 1000 women (95% CI 40 to 101) with LH compared with 111 per 1000 women with AH.

                        Reference:
                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                    • OUTCOME 2.8: Length of hospital stay

                      Narrative result:

                      Hospital stay was shorter in women undergoing LH compared with AH, although some of the subgroup analyses for type of LH were underpowered. Click below for full details.

                      Reference:
                      Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                      • Subgroup analysis 2.8.1: Length of hospital stay - [subgroup: LAVH versus AH]
                        Risk of bias of studies:

                        The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 3/4 (75%) of the studies failed to report adequate allocation concealment, none reported adequate blinding of outcome assessors and 1/4 (25%) had unclear numbers of withdrawals.

                        Narrative result:

                        Four RCTs with 466 participants found that women undergoing LH had shorter length of hospital stay compared with AH.

                        Relative effect or mean difference:

                        There was a statistically significant difference between groups, in favor of LH (mean difference -2.64 days, 95% CI -4.16 to -1.12).

                        Forest plot from Cochrane Review

                        Reference:
                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                      • Subgroup analysis 2.8.2: Length of hospital stay - [subgroup: LH(a) versus AH]
                        Risk of bias of studies:

                        The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 1/4 (25%) of the studies failed to report adequate allocation concealment, none reported adequate blinding of outcome assessors and 1/4 (25%) had unclear numbers of withdrawals.

                        Narrative result:

                        Four RCTs with 380 participants found that women undergoing LH had shorter length of hospital stay compared with AH.

                        Relative effect or mean difference:

                        There was a statistically significant difference between groups, in favor of LH (mean difference -1.82 days, 95% CI -2.34 to -1.31).

                        Forest plot from Cochrane Review

                        Reference:
                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                      • Subgroup analysis 2.8.3: Length of hospital stay - [subgroup: TLH versus AH]
                        Risk of bias of studies:

                        The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 1/2 (50%) of the studies failed to report adequate allocation concealment, none reported adequate blinding of outcome assessors and 1/2 (50%) had high numbers of withdrawals.

                        Narrative result:

                        Two RCTs with 161 participants found no statistically significant difference between groups.

                        Relative effect or mean difference:

                        There was no statistically significant difference between groups (mean difference -2.53 days, 95% CI -5.08 to 0.01).

                        Forest plot from Cochrane Review

                        Reference:
                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                      • Subgroup analysis 2.8.4: Length of hospital stay - [subgroup: LAVH versus minilaparotomy AH]
                        Risk of bias of studies:

                        The reviewers did not perform a GRADE assessment of the quality of the evidence. The study reported adequate allocation concealment, did not report adequate blinding of outcome assessors and had low numbers of withdrawals.

                        Narrative result:

                        One RCT with 100 participants found that women undergoing LH had shorter length of hospital stay compared with AH.

                        Relative effect or mean difference:

                        There was a statistically significant difference between groups, in favor of LH (mean difference -1.10 days, 95% CI -1.20 to -1.00).

                        Forest plot from Cochrane Review

                        Reference:
                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                    • OUTCOME 2.9: Other long-term complications

                      Narrative result:

                      The reviewers found no studies assessing these outcomes.

                      Reference:
                      Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]

                      3.Laparoscopic hysterectomy versus vaginal hysterectomy

                      • Population, Intervention, Comparator

                        Population:

                        Women (age range 38 to 55 years) who needed a hysterectomy for benign causes

                        Intervention:

                        Laparoscopic hysterectomy (LH): LAVH, LH(a) or TH

                        Comparator:

                        Vaginal hysterectomy (VH)

                      • OUTCOME 3.1: Return to normal activities

                        Quality of the evidence:

                        The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was moderate quality. See Summary of findings from Cochrane review

                        Narrative result:

                        Two RCTs with 140 participants found no statistically significant difference between groups, but the analysis would have been underpowered.

                        Relative effect or mean difference:

                        There was no statistically significant difference between groups (mean difference -1.07 days, 95% CI -4.21 to 2.06).

                        Forest plot from Cochrane Review

                        Reference:
                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                        • OUTCOME 3.2: Satisfaction

                          Quality of the evidence:

                          The reviewers did not perform a GRADE assessment of the quality of the evidence. The study did not report adequate allocation concealment, adequate blinding of outcome assessors and had high numbers of withdrawals.

                          Narrative result:

                          One RCT showed that after six months of treatment women who had undergone LH were more satisfied than women who underwent laparoscopic-assisted vaginal hysterectomy. The satisfaction rate was similar between patients undergoing total laparoscopic hysterectomy and non-descent vaginal hysterectomy.

                          Relative effect or mean difference:

                          Data were reported narratively.

                          Reference:
                          Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                          • OUTCOME 3.3: Urinary tract (bladder or ureter) injury

                            Quality of the evidence:

                            The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was low quality. See Summary of findings from Cochrane review

                            Narrative result:

                            Seven RCTs with 895 participants found no statistically significant difference between groups, but the analysis would have been underpowered.

                            Relative effect or mean difference:

                            There was no statistically significant difference between groups (OR 1.00, 95% CI 0.36 to 2.75).

                            Forest plot from Cochrane Review

                            Absolute effect:

                            16 per 1000 women (95% CI 6 to 42) with LH compared with 16 per 1000 women with VH.

                            Reference:
                            Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                            • OUTCOME 3.4: Vascular injury

                              Quality of the evidence:

                              The reviewers performed a GRADE assessment of the quality of evidence for this outcome at this time point and stated that the evidence was low quality. See Summary of findings from Cochrane review

                              Narrative result:

                              Four RCTs with 685 participants found no statistically significant difference between groups, but the analysis would have been underpowered.

                              Relative effect or mean difference:

                              There was no statistically significant difference between groups (OR 1.58, 95% CI 0.48 to 5.27).

                              Forest plot from Cochrane Review

                              Absolute effect:

                              19 per 1000 women (95% CI 6 to 60) with LH compared with 12 per 1000 women with VH.

                              Reference:
                              Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                              • OUTCOME 3.5: Bowel injury

                                Risk of bias of studies:

                                The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 2/3 (66%) of the studies failed to report adequate allocation concealment, none reported adequate blinding of outcome assessors and all had high numbers of withdrawals.

                                Narrative result:

                                Three RCTs with 639 participants found no events.

                                Reference:
                                Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                • OUTCOME 3.6: Long-term complications

                                  Narrative result:

                                  Rates of fistula and urinary dysfunction were similar in both groups, but both analyses were underpowered. Click below for full details.

                                  Reference:
                                  Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                  • Subgroup analysis 3.6.1: Long-term complications - [Subgroup: Fistula]
                                    Risk of bias of studies:

                                    The reviewers did not perform a GRADE assessment of the quality of the evidence. The study failed to report adequate allocation concealment, did not adequate blinding of outcome assessors and had unclear numbers of withdrawals.

                                    Narrative result:

                                    One RCT with 56 participants found no statistically significant difference between groups.

                                    Relative effect or mean difference:

                                    There was no statistically significant difference between groups (OR 0.30, 95% CI 0.01 to 7.67).

                                    Forest plot from Cochrane Review

                                    Absolute effect:

                                    11 per 1000 people (95% CI 0 to 228) with LH compared with 37 per 1000 people with VH.

                                    Reference:
                                    Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                • OUTCOME 3.7: Short-term outcomes

                                  Narrative result:

                                  The following outcomes showed similar rates in both groups: transfusion, pelvic hematoma, unintended laparotomy, vaginal cuff infection, wound/abdominal wall infection, urinary tract infection, chest infection, febrile episodes and thromboembolism, although most of the analyses were underpowered. Click below for full details.

                                  Reference:
                                  Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                  • Subgroup analysis 3.7.1: Short-term complications - [Subgroup: Thromboembolism]
                                    Risk of bias of studies:

                                    The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis the studies reported adequate allocation concealment, none reported adequate blinding of outcome assessors and both had high numbers of withdrawals.

                                    Narrative result:

                                    Two RCTs with 564 participants found no statistically significant difference between groups.

                                    Relative effect or mean difference:

                                    There was no statistically significant difference between groups (OR 1.00, 95% CI 0.15 to 6.67).

                                    Forest plot from Cochrane Review

                                    Absolute effect:

                                    We could not calculate absolute effects because of low events rate.

                                    Reference:
                                    Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                • OUTCOME 3.8: Length of hospital stay

                                  Risk of bias of studies:

                                  The reviewers did not perform a GRADE assessment of the quality of the evidence. In this analysis 2/7 (29%) of the studies failed to report adequate allocation concealment, none reported adequate blinding of outcome assessors and 1/7 (14%) had high numbers of withdrawals.

                                  Narrative result:

                                  Seven RCTs with 525 participants found that women undergoing LH had longer length of hospital stay compared with VH.

                                  Relative effect or mean difference:

                                  There was a statistically significant difference between groups, in favor of VH (mean difference 0.88 days, 95% CI 0.73 to 1.03).

                                  Forest plot from Cochrane Review

                                  Reference:
                                  Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                  • OUTCOME 3.9: Other long-term complications

                                    Narrative result:

                                    The reviewers found no studies assessing these outcomes.

                                    Reference:
                                    Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]

                                    4.Robotic-assisted hysterectomy versus laparoscopic hysterectomy

                                    • Population, Intervention, Comparator

                                      Population:

                                      Women (mean age 46 years) with indication for hysterectomy because of benign lesions and vaginal hysterectomy expected to be difficult because of myomas or nulliparity

                                      Intervention:

                                      Robotic-assisted hysterectomy (RH)

                                      Comparator:

                                      Laparoscopic hysterectomy (LH)

                                    • OUTCOME 4.1: Return to normal activities

                                      Risk of bias of studies:

                                      The reviewers did not perform a GRADE assessment of the quality of the evidence. The study failed to report adequate allocation concealment, did not report adequate blinding of outcome assessors and had unclear numbers of withdrawals.

                                      Narrative result:

                                      One RCT with 100 participants found no statistically significant difference between groups, but the study would have been underpowered.

                                      Relative effect or mean difference:

                                      There was no statistically significant difference between groups (mean difference -2.40 days, 95% CI -8.54 to 3.74).

                                      Forest plot from Cochrane Review

                                      Reference:
                                      Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                      • OUTCOME 4.2: Intraoperative visceral injury

                                        Narrative result:

                                        This outcome was assessed by a single underpowered study and no obvious difference between groups was seen for any type of visceral injury. Click below for full details.

                                        Reference:
                                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                        • Subgroup analysis 4.2.1: Intraoperative visceral injury (dichotomous) - [subgroup: Ureter injury]
                                          Risk of bias of studies:

                                          The reviewers did not perform a GRADE assessment of the quality of the evidence. The study failed to report adequate allocation concealment, did not report adequate blinding of outcome assessors and had unclear numbers of withdrawals.

                                          Narrative result:

                                          One RCT with 100 participants found no statistically significant difference between groups.

                                          Relative effect or mean difference:

                                          There was no statistically significant difference between groups (OR 0.33, 95% CI 0.01 to 8.21).

                                          Forest plot from Cochrane Review

                                          Absolute effect:

                                          7 per 1000 women (95% CI 0 to 144) with RH compared with 20 per 1000 women with LH.

                                          Reference:
                                          Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                        • Subgroup analysis 4.2.2: Intraoperative visceral injury (dichotomous) - [subgroup: Vascular injury]
                                          Risk of bias of studies:

                                          The reviewers did not perform a GRADE assessment of the quality of the evidence. The study failed to report adequate allocation concealment, did not report adequate blinding of outcome assessors and had unclear numbers of withdrawals.

                                          Narrative result:

                                          One RCT with 100 participants found no statistically significant difference between groups.

                                          Relative effect or mean difference:

                                          There was no statistically significant difference between groups (OR 1.00, 95% CI 0.06 to 16.44).

                                          Forest plot from Cochrane Review

                                          Absolute effect:

                                          20 per 1000 women (95% CI 1 to 251) with RH compared with 20 per 1000 women with LH.

                                          Reference:
                                          Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                      • OUTCOME 4.3: Short-term complications

                                        Narrative result:

                                        Rates of transfusion and wound/abdominal infection were similar in both groups, but the study was underpowered. Click below for full details.

                                        Reference:
                                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                        • Subgroup analysis 4.3.1: Short term complications - [subgroup: Wound/abdominal wall infection]
                                          Risk of bias of studies:

                                          The reviewers did not perform a GRADE assessment of the quality of the evidence. The study failed to report adequate allocation concealment, did not report adequate blinding of outcome assessors and had unclear numbers of withdrawals.

                                          Narrative result:

                                          One RCT with 100 participants found no statistically significant difference between groups.

                                          Relative effect or mean difference:

                                          There was no statistically significant difference between groups (OR 0.33, 95% CI 0.01 to 8.21).

                                          Forest plot from Cochrane Review

                                          Absolute effect:

                                          7 per 1000 women (95% CI 0 to 144) with RH compared with 20 per 1000 women with LH.

                                          Reference:
                                          Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]
                                      • OUTCOME 4.4: Satisfaction, Bowel injury, Long-term complications, Other short-term complications, Length of hospital stay

                                        Narrative result:

                                        The reviewers found no studies assessing these outcomes.

                                        Reference:
                                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]

                                        Additional Information:

                                        DOI

                                        10.1002/cca.1225

                                        Publication Dates

                                        1. Published Online: 2 DEC 2016

                                        CCA derived from

                                        Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677.pub5. [Review search date: August 2014]

                                        How to Cite

                                        In women with benign gynecological disease, how do different approaches to hysterectomy compare at improving outcomes? Sera Tort (MD) and George Salamalekis (MD, MSc, PhD) (on behalf of Cochrane Clinical Answers Editors). Cochrane Clinical Answers 2016. DOI: 10.1002/cca.1225.

                                        Further Information

                                        • CCA Associate editor: Sera Tort (MD), Clinical Editor, Cochrane Editorial Unit, London, UK.
                                        • CCA Associate editor: George Salamalekis (MD, MSc, PhD), Obstetrician Gynaecologist, National & Kapodistrian University of Athens, Chaidari, Athens, Greece.
                                        • CCA Editor: Karen Pettersen. Correspondence to kpettersen@wiley.com.