Vaginal hysterectomy leads to better outcomes than abdominal surgery

A review of recent studies concludes that surgeons should perform vaginal rather than abdominal hysterectomies whenever possible in order to cut down on complications and the length of hospital stays.1

According to the systematic evidence review by Dr. Neil Johnson of the University of Auckland in New Zealand and colleagues, women who had vaginal hysterectomies had fewer infections and high temperatures after surgery compared to those who had abdominal hysterectomies. Women with vaginal hysterectomies also returned to their normal activities quicker than those who had the abdominal surgery, the researchers found.

The better outcomes associated with vaginal hysterectomy suggest it “should be performed in preference to abdominal hysterectomy where possible,” Johnson says. But “the surgical approach to hysterectomy should be decided by a woman in discussion with her surgeon in light of the relative benefits and hazards,” he adds.

The review appears in the January issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

In a vaginal hysterectomy, surgeons remove the uterus through the vaginal opening. Vaginal hysterectomies are usually performed when the uterus is a normal size. Abdominal hysterectomies, where the uterus is removed through an abdominal opening, has traditionally been used when a woman has an enlarged uterus, malignant tumors or conditions such as endometriosis.

The Cochrane researchers also reviewed the evidence comparing laparoscopic and abdominal hysterectomy. In laparoscopic hysterectomies, the uterus is removed with the help of specialized instruments and a small fiber optic camera inserted through a small incision in the abdomen. Some laparoscopic hysterectomies also include a vaginal surgical component.

Johnson and colleagues concluded that the laparoscopic procedure had some of the same advantages as vaginal hysterectomies, such as shorter hospital stays and fewer complications like infection. They also noted, however, that laparoscopic hysterectomies are longer operations than abdominal or vaginal hysterectomies and may carry a greater risk of damaging the bladder or ureter, the tube that leads from the kidney to the bladder. “There were conflicting data on which was the quickest operation to perform and this presumably relates to the prior experience with these procedures of the surgeons involved in the trials,” Johnson says.

None of the studies reported a significant cost difference between laparoscopic and abdominal hysterectomies, but one study found that laparoscopic hysterectomies were significantly more costly than vaginal hysterectomies. The Cochrane researchers reviewed data from 27 studies that included 3,643 women, most of whom were between age 41 and 50. Each of the studies included in the analysis was a randomized controlled trial directly comparing one type of hysterectomy with another. “The introduction of the newer techniques of laparoscopic hysterectomy has, we feel, made us all look more critically, not only at the newer approaches, but indeed at all approaches to hysterectomy,” Johnson says.

According to a 2002 report by the Centers for Disease Control and Prevention, hysterectomy is the second most frequently performed surgery, after caesarean section, for women of reproductive age. About 600,000 hysterectomies are performed each year in the United States. More than 60 percent of hysterectomies performed between 1994 and 1999 were abdominal, according to the CDC report.

Johnson says the percentage of hysterectomies performed by each of the surgical approaches “varies markedly across countries, within the same country and even between individual surgeons working within the same unit.” Lower rates of vaginal hysterectomy do not necessarily mean that the technique is being avoided, but rather underutilized, Johnson says, “perhaps because some gynecologists have had insufficient training in the vaginal approach to hysterectomy.”

Amanda Hall, a spokesperson for the American College of Gynecologists, says the organization has no official recommendation. “It’s really a case-by-case basis,” she says. According to the 2002 CDC study, rates of laparoscopy-assisted vaginal hysterectomies more than doubled between 1994 and 1999, from 13 percent of all vaginal hysterectomies to 28 percent. “Where vaginal hysterectomy is not possible, a laparoscopic approach may avoid the need for an abdominal hysterectomy,” Johnson says, but he stresses that more research on laparascopic techniques is needed.

Johnson says future studies comparing hysterectomy type should focus on long-term effects, such as urinary and sexual dysfunction and the formation of fistulas, holes in the vagina, bladder or rectum that often lead to incontinence.

1. Johnson et al. Surgical approach to hysterectomy for benign gynaecological disease. The Cochrane Database of Systematic Reviews 2005, Issue 1