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. 2023 Aug 29;8(8):CD003677.
doi: 10.1002/14651858.CD003677.pub6.

Surgical approach to hysterectomy for benign gynaecological disease

Charlotte M Pickett  1 , Dachel D Seeratan  2 , Ben Willem J Mol  3 , Theodoor E Nieboer  4 , Neil Johnson  5 , Tijmen Bonestroo  6 , Johanna Wm Aarts  7
Affiliations

Surgical approach to hysterectomy for benign gynaecological disease

Charlotte M Pickett et al. Cochrane Database Syst Rev. .

Abstract

Background: Currently, there are five major approaches to hysterectomy for benign gynaecological disease: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robotic-assisted hysterectomy (RH) and vaginal natural orifice hysterectomy (V-NOTES). Within the LH category we further differentiate the laparoscopic-assisted vaginal hysterectomy (LAVH) from the total laparoscopic hysterectomy (TLH) and single-port laparoscopic hysterectomy (SP-LH).

Objectives: To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions.

Search methods: We searched the following databases (from their inception to December 2022): the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the trial registries and relevant reference lists, and communicated with experts in the field for any additional trials.

Selection criteria: We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another.

Data collection and analysis: At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction and quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvic-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

Main results: We included 63 studies with 6811 women. The evidence for most comparisons was of low or moderate certainty. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (12 RCTs, 1046 women) Return to normal activities was probably faster in the VH group (mean difference (MD) -10.91 days, 95% confidence interval (CI) -17.95 to -3.87; 4 RCTs, 274 women; I2 = 67%; moderate-certainty evidence). This suggests that if the return to normal activities after AH is assumed to be 42 days, then after VH it would be between 24 and 38 days. We are uncertain whether there is a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (28 RCTs, 3431 women) Return to normal activities may be sooner in the LH group (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, 618 women; I2 = 68%, low-certainty evidence), but there may be more urinary tract injuries in the LH group (odds ratio (OR) 2.16, 95% CI 1.19 to 3.93; 18 RCTs, 2594 women; I2 = 0%; moderate-certainty evidence). This suggests that if the return to normal activities after abdominal hysterectomy is assumed to be 37 days, then after laparoscopic hysterectomy it would be between 22 and 25 days. It also suggests that if the rate of ureter injury during abdominal hysterectomy is assumed to be 0.2%, then during laparoscopic hysterectomy it would be between 0.2% and 2%. We are uncertain whether there is a difference between the groups for the other primary outcomes. LH versus VH (22 RCTs, 2135 women) We are uncertain whether there is a difference between the groups for any of our primary outcomes. Both short- and long-term complications were rare in both groups. Robotic-assisted hysterectomy (RH) versus LH (three RCTs, 296 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for our other primary outcomes. Single-port laparoscopic hysterectomy (SP-LH) versus LH (seven RCTs, 621 women) None of the studies reported satisfaction rates, quality of life or major long-term complications. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury. Total laparoscopic hysterectomy (TLH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) (three RCTs, 233 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury or major long-term complications. Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) versus LH (two RCTs, 96 women) We are uncertain whether there is a difference between the groups for rates of bladder injury. Our other primary outcomes were not reported. Overall, adverse events were rare in the included studies.

Authors' conclusions: Among women undergoing hysterectomy for benign disease, VH appears to be superior to AH. When technically feasible, VH should be performed in preference to AH because it is associated with faster return to normal activities, fewer wound/abdominal wall infections and shorter hospital stay. Where VH is not possible, LH has advantages over AH including faster return to normal activities, shorter hospital stay, and decreased risk of wound/abdominal wall infection, febrile episodes or unspecified infection, and transfusion. These advantages must be balanced against the increased risk of ureteric injury and longer operative time. When compared to LH, VH was associated with no difference in time to return to normal activities but shorter operative time and shorter hospital stay. RH and V-NOTES require further evaluation since there is a lack of evidence of any patient benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed with the patient and decided in the light of the relative benefits and hazards. Surgical expertise is difficult to quantify and poorly reported in the available studies and this may influence outcomes in ways that cannot be accounted for in this review. In conclusion, when VH is not feasible, LH has multiple advantages over AH, but at the cost of more ureteric injuries. Evidence is limited for RH and V-NOTES.

Trial registration: ClinicalTrials.gov NCT05031182.

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Conflict of interest statement

Charlotte Pickett has no declarations of interest.

Dachel Seeratan has no declarations of interest.

Tijmen Bonestroo has no declarations of interest.

Theodoor E Nieboer has no declarations of interest.

Neil Johnson is a fiduciary officer of World Endometriosis Society and Asia Pacific Initiative in Reproduction (ASPIRE); has received financial remuneration for consultancies from Myovant Sciences and Roche Diagnostics GmbH; and has received research funding from Guerbet and Abbott Pharmaceuticals.

Ben Willem Mol has received financial remuneration for consultancies from Merck, Guerbet LLC and ObcEva.

Johanna WM Aarts has no declarations of interest.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each methodological quality item presented as percentages across all included studies.
3
3
4
4
5
5
Funnel plot for length of hospital stay for laparoscopic hysterectomy versus abdominal hysterectomy comparision.
6
6
1.1
1.1. Analysis
Comparison 1: VH versus AH, Outcome 1: Return to normal activities (days)
1.2
1.2. Analysis
Comparison 1: VH versus AH, Outcome 2: Long‐term outcomes: satisfaction (dichotomous)
1.3
1.3. Analysis
Comparison 1: VH versus AH, Outcome 3: Intraoperative visceral injury (dichotomous)
1.4
1.4. Analysis
Comparison 1: VH versus AH, Outcome 4: Long‐term complications (dichotomous)
1.5
1.5. Analysis
Comparison 1: VH versus AH, Outcome 5: Operation time (mins)
1.6
1.6. Analysis
Comparison 1: VH versus AH, Outcome 6: Short‐term outcomes (dichotomous)
1.7
1.7. Analysis
Comparison 1: VH versus AH, Outcome 7: Length of hospital stay (days)
2.1
2.1. Analysis
Comparison 2: LH versus AH, Outcome 1: Return to normal activities (days)
2.2
2.2. Analysis
Comparison 2: LH versus AH, Outcome 2: Satisfaction
2.3
2.3. Analysis
Comparison 2: LH versus AH, Outcome 3: Bladder injury
2.4
2.4. Analysis
Comparison 2: LH versus AH, Outcome 4: Ureter injury
2.5
2.5. Analysis
Comparison 2: LH versus AH, Outcome 5: Urinary tract (bladder or ureter) injury
2.6
2.6. Analysis
Comparison 2: LH versus AH, Outcome 6: Bowel injury
2.7
2.7. Analysis
Comparison 2: LH versus AH, Outcome 7: Vascular injury
2.8
2.8. Analysis
Comparison 2: LH versus AH, Outcome 8: Fistula
2.9
2.9. Analysis
Comparison 2: LH versus AH, Outcome 9: Urinary dysfunction
2.10
2.10. Analysis
Comparison 2: LH versus AH, Outcome 10: Operation time (mins)
2.11
2.11. Analysis
Comparison 2: LH versus AH, Outcome 11: Bleeding
2.12
2.12. Analysis
Comparison 2: LH versus AH, Outcome 12: Transfusion
2.13
2.13. Analysis
Comparison 2: LH versus AH, Outcome 13: Pelvic haematoma
2.14
2.14. Analysis
Comparison 2: LH versus AH, Outcome 14: Length of hospital stay (days)
2.15
2.15. Analysis
Comparison 2: LH versus AH, Outcome 15: Vaginal cuff infection
2.16
2.16. Analysis
Comparison 2: LH versus AH, Outcome 16: Wound/abdominal wall infection
2.17
2.17. Analysis
Comparison 2: LH versus AH, Outcome 17: Urinary tract infection
2.18
2.18. Analysis
Comparison 2: LH versus AH, Outcome 18: Chest infection
2.19
2.19. Analysis
Comparison 2: LH versus AH, Outcome 19: Febrile episodes or unspecified infection
2.20
2.20. Analysis
Comparison 2: LH versus AH, Outcome 20: Thromboembolism
2.21
2.21. Analysis
Comparison 2: LH versus AH, Outcome 21: Wound dehiscence
3.1
3.1. Analysis
Comparison 3: LH versus VH, Outcome 1: Return to normal activities (days)
3.2
3.2. Analysis
Comparison 3: LH versus VH, Outcome 2: Ureter injury
3.3
3.3. Analysis
Comparison 3: LH versus VH, Outcome 3: Bladder injury
3.4
3.4. Analysis
Comparison 3: LH versus VH, Outcome 4: Urinary tract (bladder or ureter) injury
3.5
3.5. Analysis
Comparison 3: LH versus VH, Outcome 5: Bowel injury
3.6
3.6. Analysis
Comparison 3: LH versus VH, Outcome 6: Vascular injury
3.7
3.7. Analysis
Comparison 3: LH versus VH, Outcome 7: Fistula
3.8
3.8. Analysis
Comparison 3: LH versus VH, Outcome 8: Urinary dysfunction
3.9
3.9. Analysis
Comparison 3: LH versus VH, Outcome 9: Operation time (mins)
3.10
3.10. Analysis
Comparison 3: LH versus VH, Outcome 10: Bleeding
3.11
3.11. Analysis
Comparison 3: LH versus VH, Outcome 11: Transfusion
3.12
3.12. Analysis
Comparison 3: LH versus VH, Outcome 12: Pelvic haematoma
3.13
3.13. Analysis
Comparison 3: LH versus VH, Outcome 13: Unintended laparotomy
3.14
3.14. Analysis
Comparison 3: LH versus VH, Outcome 14: Vaginal cuff infection
3.15
3.15. Analysis
Comparison 3: LH versus VH, Outcome 15: Wound/abdominal wall infection
3.16
3.16. Analysis
Comparison 3: LH versus VH, Outcome 16: Urinary tract infection
3.17
3.17. Analysis
Comparison 3: LH versus VH, Outcome 17: Chest infection
3.18
3.18. Analysis
Comparison 3: LH versus VH, Outcome 18: Febrile episodes or unspecified infection
3.19
3.19. Analysis
Comparison 3: LH versus VH, Outcome 19: Thromboembolism
3.20
3.20. Analysis
Comparison 3: LH versus VH, Outcome 20: Length of hospital stay (days)
4.1
4.1. Analysis
Comparison 4: RH versus LH, Outcome 1: Return to normal activities (days)
4.2
4.2. Analysis
Comparison 4: RH versus LH, Outcome 2: Intraoperative visceral injury (dichotomous)
4.3
4.3. Analysis
Comparison 4: RH versus LH, Outcome 3: Operation time
4.4
4.4. Analysis
Comparison 4: RH versus LH, Outcome 4: Bleeding
4.5
4.5. Analysis
Comparison 4: RH versus LH, Outcome 5: Wound dehiscence
4.6
4.6. Analysis
Comparison 4: RH versus LH, Outcome 6: Transfusion
4.7
4.7. Analysis
Comparison 4: RH versus LH, Outcome 7: Wound/abdominal wall infection
4.8
4.8. Analysis
Comparison 4: RH versus LH, Outcome 8: Febrile episodes or unspecified infections
5.1
5.1. Analysis
Comparison 5: SP‐LH versus LH, Outcome 1: Bladder injury
5.2
5.2. Analysis
Comparison 5: SP‐LH versus LH, Outcome 2: Ureter injury
5.3
5.3. Analysis
Comparison 5: SP‐LH versus LH, Outcome 3: Conversion or aditional port placement
5.4
5.4. Analysis
Comparison 5: SP‐LH versus LH, Outcome 4: Transfusion
5.5
5.5. Analysis
Comparison 5: SP‐LH versus LH, Outcome 5: Pelvic haematoma
5.6
5.6. Analysis
Comparison 5: SP‐LH versus LH, Outcome 6: Wound/abdominal wall infection
5.7
5.7. Analysis
Comparison 5: SP‐LH versus LH, Outcome 7: Febrile episodes or unspecified infection
5.8
5.8. Analysis
Comparison 5: SP‐LH versus LH, Outcome 8: Vaginal cuff dehiscence
5.9
5.9. Analysis
Comparison 5: SP‐LH versus LH, Outcome 9: Postoperative ileus
5.10
5.10. Analysis
Comparison 5: SP‐LH versus LH, Outcome 10: Operation time (mins)
5.11
5.11. Analysis
Comparison 5: SP‐LH versus LH, Outcome 11: Length of hospital stay (days)
6.1
6.1. Analysis
Comparison 6: TLH versus LAVH, Outcome 1: Intraoperative visceral injury (dichotomous)
6.2
6.2. Analysis
Comparison 6: TLH versus LAVH, Outcome 2: Long‐term complications (dichotomous)
6.3
6.3. Analysis
Comparison 6: TLH versus LAVH, Outcome 3: Operation time (mins)
6.4
6.4. Analysis
Comparison 6: TLH versus LAVH, Outcome 4: Unintended laparotomy
6.5
6.5. Analysis
Comparison 6: TLH versus LAVH, Outcome 5: Short‐term outcomes (dichotomous)
6.6
6.6. Analysis
Comparison 6: TLH versus LAVH, Outcome 6: Length of hospital stay (days)
7.1
7.1. Analysis
Comparison 7: V‐NOTES versus LH, Outcome 1: Conversion or additional port placement
7.2
7.2. Analysis
Comparison 7: V‐NOTES versus LH, Outcome 2: Operation time
7.3
7.3. Analysis
Comparison 7: V‐NOTES versus LH, Outcome 3: Bladder injury
7.4
7.4. Analysis
Comparison 7: V‐NOTES versus LH, Outcome 4: Febrile episodes or unspecified infection
7.5
7.5. Analysis
Comparison 7: V‐NOTES versus LH, Outcome 5: Length of hospital stay (days)
7.6
7.6. Analysis
Comparison 7: V‐NOTES versus LH, Outcome 6: Substantial bleeding
7.7
7.7. Analysis
Comparison 7: V‐NOTES versus LH, Outcome 7: Wound/abdominal wall infection
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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    1. Parveen T, Kausar T, Iqbal T, Batool A. Comparison of outcome between vaginal and abdominal hysterectomy. Pakistan Journal of Medical & Health Sciences 2013;7(4):1150-3.
Perino 1999 {published data only}
    1. Perino A, Cucinella G, Venezia R, Castelli A, Cittadini E. Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study. Human Reproduction 1999;14(12):2996-9. - PubMed
Persson 2006 {published data only}
    1. Persson P, Kjolhede P. Factors associated with postoperative recovery after laparoscopic and abdominal hysterectomy. European Journal of Obstetrics & Gynecology and Reproductive Biology 2008;140(1):108-13. - PubMed
    1. Persson P, Wijma K, Hammar M, Kjolhede P. Psychological well being after laparoscopic and abdominal hysterectomy - a randomised controlled multicentre study. British Journal of Obstetrics and Gynecology 2006;113(9):1023-30. - PubMed
Raju 1994 {published data only}
    1. Raju KS, Auld BJ. A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. British Journal of Obstetrics & Gynaecology 1994;101(12):1068-71. - PubMed
Ribeiro 2003 {published data only}
    1. Ribeiro SC, Ribeiro RM, Santos NC, Pinotti JA. A randomized study of total abdominal, vaginal and laparoscopic hysterectomy. International Journal of Gynecology and Obstetrics 2003;83(1):37-43. - PubMed
Richardson 1995 {published data only}
    1. Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterectomy a waste of time? Lancet 1995;345(8941):36-41. - PubMed
Roy 2011 {published data only}
    1. Roy KK, Goyal M, Singla S, Sharma JB, Malhotra N, Kumar S. A prospective randomised study of total laparoscopic hysterectomy, laparoscopically assisted vaginal hysterectomy and non-descent vaginal hysterectomy for the treatment of benign diseases of the uterus. Archives of Gynecology and Obstetrics 2011;284(4):907-12. - PubMed
Roy 2012 {published data only}
    1. Roy KK, Subbaiah M, Singla S, Kumar S, Sharma JB, Mitra DK. Role of serum interleukin-6 in comparing surgical stress after laparoscopic-assisted vaginal hysterectomy and non-descent vaginal hysterectomy for large uteri. Archives of Gynecology and Obstetrics 2012;285(3):671-6. - PubMed
Sarlos 2012 {published data only}
    1. Sarlos D, Kots L, Stevanovic N, Felten S, Schär G. Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstetrics & Gynecology 2012;120(3):604-11. - PubMed
Schütz 2002 {published data only}
    1. Schütz K, Possover M, Merker A, Michels A, Schneider A. Prospective randomized comparison of laparoscopic-assisted vaginal hysterectomy (LAVH) with abdominal hysterectomy (AH) for the treatment of the uterus weighing >200g. Surgical Endoscopy 2002;16(1):121-5. - PubMed
Seracchioli 2002 {published data only}
    1. Seracchioli R, Venturoli S, Vianello F, Govoni F, Cantarelli M, Gualerzi B, et al. Total laparoscopic hysterectomy compared with abdominal hysterectomy in the presence of a large uterus. Journal of the American Association of Gynecologic Laparoscopists 2002;9(3):333-8. - PubMed
Sesti 2008a {published data only}
    1. Sesti F, Calonzi F, Ruggeri V, Pietropoli A, Piccione E. A comparison of vaginal, laparoscopic-assisted vaginal, and minilaparotomy hysterectomies for enlarged myomatous uteri. International Journal of Gynecology and Obstetrics 2008;103(3):227-31. - PubMed
Sesti 2008b {published data only}
    1. Sesti F, Ruggeri V, Pietropolli A, Piccione E. Laparoscopically assisted vaginal hysterectomy versus vaginal hysterectomy for enlarged uterus. Journal of the Society of Laparoendoscopic Surgeons 2008;12:246-51. - PMC - PubMed
Sesti 2014b {published data only}
    1. Sesti F, Cosi V, Calonzi F, Ruggeri V, Pietropolli A, Di Francesco L, et al. Randomized comparison of total laparoscopic, laparoscopically assisted vaginal and vaginal hysterectomies for myomatous uteri. Archives of Gynecology and Obstetrics 2014;290(3):485–91. - PubMed
Silva Filho 2006 {published data only}
    1. Silva-Filho AL, Werneck RA, Magalhaes RS, Belo AV, Triginelli SA. Abdominal vs vaginal hysterectomy: a comparative study of postoperative quality of life and satisfaction. Archives of Gynecology and Obstetrics 2006;274(1):21-4. - PubMed
Song 2013 {published data only}
    1. Song T, Cho J, Kim TJ, Kim IR, Hahm TS, Kim BG, et al. Cosmetic outcomes of laparoendoscopic single-site hysterectomy compared with multi-port surgery: randomized controlled trial. Journal of Minimally Invasive Gynecology 2013;20(4):460-7. [DOI: 10.1016/j.jmig.2013.01.010] - DOI - PubMed
Soriano 2001 {published data only}
    1. Soriano D, Goldstein A, Lecuru F, Darai E. Recovery from vaginal hysterectomy compared with laparoscopy-assisted hysterectomy: a prospective, randomized, multicenter study. Acta Obstetrica et Gynaecologica Scandinavica 2001;80(4):337-41. - PubMed
Summitt 1992 {published data only}
    1. Summitt RL Jr, Stovall TG, Lipscomb GH, Ling FW. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstetrics and Gynecology 1992;80(6):895-901. - PubMed
Summitt 1998 {published data only}
    1. Summitt RL Jr, Stovall TG, Steege JF, Lipscomb GH. A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstetrics and Gynecology 1998;92(3):321-6. - PubMed
Tormena 2017 {published data only}
    1. Tormena RA, Ribeiro SC, Soares Júnior JM, Maciel GAR, Baracat EM. A prospective randomized study of the inflammatory responses to multiport and singleport laparoscopic hysterectomies. Acta Cirurgica Brasileira 2017;32(7):576-86. - PubMed
Tsai 2003 {published data only}
    1. Tsai EM, Chen HS, Long CY, Yang CH, Hsu SC, Wu CH, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a study of 100 cases on light-endorsed transvaginal section. Gynecologic and Obstetric Investigation 2003;55(2):105-9. - PubMed
Wakhloo 2015 {published data only}
    1. Wakhloo A, Dubey S, Gupta S. Outcome of laparoscopic and abdominal hysterectomy: a comparative study. JK Science 2015;17(4):177-81.
Yuen 1998 {published data only}
    1. Yuen PM, Mak TWL, Yim SF, Ngan Kee WD, Lam CWK, Rogers MS, et al. Metabolic and inflammatory responses after laparoscopic and abdominal hysterectomy. American Journal of Obstetrics and Gynecology 1998;179(1):1-5. - PubMed
Zhu 2009 {published data only}
    1. Zhu L, Lang JH, Liu CY, Shi HH, Sun ZJ, Fan R. Clinical assessment for three routes of hysterectomy. Chinese Medical Journal 2009;122(4):377-80. - PubMed

References to studies excluded from this review

Aka 2004 {published data only}
    1. Aka N, Köse G, Gönenc I, Api M. Tissue trauma after vaginal hysterectomy and colporrhaphy versus abdominal hysterectomy: a randomised controlled study. Australian and New Zealand Journal of Obstetrics and Gynaecology 2004;44(4):328-31. - PubMed
Apoola 1998 {published data only}
    1. Apoola A, Hefni MA. Hysterectomy for moderately enlarged uterus: abdominal versus vaginal hysterectomy. Journal of Obstetrics and Gynaecology 1998;18(4):375-6. - PubMed
Atabekoglu 2004 {published data only}
    1. Atabekoglu C, Sönmezer M, Güngör M, Aytaç R, Ortaç F, Unlü C. Tissue trauma in abdominal and laparoscopic-assisted vaginal hysterectomy. Journal of the American Association Gynaecological Laparoscopists 2004;11(1):467-72. - PubMed
Balakrishnan 2016 {published data only}
    1. Balakrishnan D, Dibyajyoti G. A comparison between non-descent vaginal hysterectomy and total abdominal hysterectomy. Journal of Clinical and Diagnostic Research 2016;10(1):11-14. - PMC - PubMed
Beguinot 2020 {published data only}
    1. Beguinot M, Botchorishvili R, Comptour A, Curinier S, Campagne-Loiseau S, Chauvet P, et al. Minilaparoscopic total hysterectomy in current practice feasibility and benefits: a unicentric, randomized controlled trial. Journal of Minimally Invasive Gynecology 2020;27(3):673-80. - PubMed
Cardone 2010 {published data only}
    1. Cardone A, Zarcone R, Giardiello M. Comparison of 100 of hysterectomy laparoscopic against 100 cases hysterectomy laparotomy. Minerva Ginecologica 2010;62(3):171-7. - PubMed
Celik 2008 {published data only}
    1. Celik H, Gurates B, Yavuz A, Nurkalem C, Hanay F, Kavak B. The effect of hysterectomy and bilaterally salpingo-oophorectomy on sexual function in post-menopausal women. Maturitas 2008;61(4):358-63. - PubMed
Chapron 1999 {published data only}
    1. Chapron C, Laforest L, Ansquer Y, Fauconnier A, Fernandez B, Breart G, et al. Hysterectomy techniques used for benign pathologies: results of a French multicentre study. Human Reproduction 1999;14(10):2464-70. - PubMed
Chen 2021 {published data only}
    1. Chen J, McIntire D, Kho K. Achievement of self-reported goals from a randomized trial of laparoscopic versus abdominal hysterectomy for benign indications. Journal of Minimally Invasive Gynecology 2021;28(11):86-7.
Cucinella 2000 {published data only (unpublished sought but not used)}
    1. Cucinella G, Gugliotta G, Adile B. Total laparoscopic hysterectomy versus total abdominal hysterectomy: a confront of 100 versus 101 cases in prospective randomized study. In: XVI FIGO World Congress Abstract Book 3. Washington DC. 2000:45.
Davies 1998 {published data only (unpublished sought but not used)}
    1. Davies A. Randomized controlled trial comparing oophorectomy at vaginal and laparoscopically assisted vaginal hysterectomy. In: British Journal of Obstetrics and Gynaecology, poster abstract 1998.
Demir 2008 {published data only}
    1. Demir A, Bige O, Saatli B, Solak A, Saygili U, Önvural A. Prospective comparison of tissue trauma after laparoscopic hysterectomy types with retroperitoneal lateral transsection of uterine vessels using ligasure and abdominal hysterectomy. Archives of Gynecology and Obstetrics 2008;277(4):325-30. - PubMed
Drahonovsky 2006 {published data only}
    1. Drahonovsky J, Pan M, Baresova S, Kucera E, Feyereisl J. Clinical comparison of laparoscopy-assisted vaginal hysterectomy (LAVH) and total laparoscopy hysterectomy (TLH) in women with benign disease of uterus - a prospective randomized study [Klinické srovnání laparoskopicky asistované vaginální hysterektomie (LAVH) a totální laparoskopické hysterektomie (TLH) u zen s benigním onemocnemím delohy - prospektivní randomizovaná studie]. Ceska Gynekologie 2006;71(6):431-7. - PubMed
Drahonovsky 2010 {published data only}
    1. Drahonovsky J, Haakova L, Otcenasek M, Krofta L, Kucera E, Feyereisl J. A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease. European Journal of Obstetrics & Gynecology and Reproductive Biology 2010;148(2):172-6. - PubMed
Dua 2012 {published data only}
    1. Dua A, Galimberti A, Subramaniam M, Popli G, Radley S. The effects of vault drainage on postoperative morbidity after vaginal hysterectomy for benign gynaecological disease: a randomised controlled trial. BJOG 2012;119(3):348-53. - PubMed
Elessawy 2020 {published data only}
    1. Elessawy M, Schneekloth S, Günther V, Maass N, Mettler L, Alkatout I. Postoperative telephone-based questionnaire on quality of life after robotic-assisted laparoscopic hysterectomy versus conventional total laparoscopic hysterectomy. Journal of Clinical Medicine 2020 ;9(9):2849. - PMC - PubMed
Ellstrom 2003 {published data only}
    1. Ellstrom MA, Astrom M, Moller A, Olsson JH, Hahlin M. A randomized trial comparing changes in psychological well-being and sexuality after laparoscopic and abdominal hysterectomy. Acta Obstetrica et Gynaecologica Scandinavica 2003;82(9):871-5. - PubMed
Fanfani 2013 {published data only}
    1. Fanfani F, Fagotti A, Gagliardi ML, Monterossi G, Rossitto C, Costantini B, et al. Minilaparoscopic versus single-port total hysterectomy: a randomized trial. Journal of Minimally Invasive Gynecology 2013;20(2):192-7. - PubMed
Fathi 2022 {published data only}
    1. Fathi A, Saleh MM, Shetiwy M, Elzahaby IA, Farouk O, Shams N, et al. Operative outcomes of single-incision laparoscopic hysterectomy vs conventional laparoscopic total hysterectomy: a prospective randomized controlled study. Surgical Innovation 2022;29(5):590-9. - PubMed
Ghanbari 2009 {published data only}
    1. Ghanbari Z, Baratali BH, Foroughifar T, Pesikhani MD, Shariat M. Pfannenstiel versus Maylard incision for gynecologic surgery: a randomized, double-blind controlled trial. Taiwanese Journal of Obstetrics & Gynecology 2009;48(2):120-3. - PubMed
Ghezzi 2011 {published data only}
    1. Ghezzi F, Cromi A, Siesto G, Uccella S, Boni L, Serati M, et al. Minilaparoscopic versus conventional laparoscopic hysterectomy: results of a randomized trial. Journal of Minimally Invasive Gynecology 2011;18(4):455-61. - PubMed
Hahlin 1994 {published data only}
    1. Hahlin M, Ellstrom M, Olsson JH. Laparoscopic hysterectomy. Further knowledge of advantages and disadvantages is necessary [Laparoskopisk hysterektomi. Ytterligare kunskaper om för- och nackdelar behövs]. Lakartidningen 1994;91(4):220-2. - PubMed
Holub 2000 {published data only}
    1. Holub Z, Jabor A, Kliment L, Voracek J, Lukac J. Comparison of two procedures for laparovaginal hysterectomy: a randomized trial. European Journal of Obstetrics and Gynecology 2000;90(1):31-6. - PubMed
Horng 2004 {published data only}
    1. Horng SG, Huang KG, Lo TS, Soong YK. Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH. Journal of the American Association of Gynaecologic Laparoscopists 2004;11(1):42-6. - PubMed
Howard 1993 {published data only}
    1. Howard FM, Sanchez R. A comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy. Journal of Gynecologic Surgery 1993;9(2):83-9. - PubMed
Kim 2010 {published data only}
    1. Kim TK, Yoon JR. Comparison of the neuroendocrine and inflammatory responses after laparoscopic and abdominal hysterectomy. Korean Journal of Anesthesiology 2010;59(4):265-9. - PMC - PubMed
Kucukozkan 2011 {published data only}
    1. Kucukozkan T, Ozkaya E, Ucar FO, Kara OF. Hysterectomy for large symptomatic myomas: minilaparotomy versus midline vertical incision. Archives of Gynecology and Obstetrics 2011;284(2):421-5. - PubMed
Lee 2011 {published data only}
    1. Lee JH, Choi JS, Hong JH, Joo KJ, Kim BY. Does conventional or single port laparoscopically assisted vaginal hysterectomy affect female sexual function? Acta Obstetricia et Gynecologica Scandinavica 2011;90(12):1410-5. - PubMed
Li 2012 {published data only}
    1. Li M, Han Y, Feng YC. Single-port laparoscopic hysterectomy versus conventional laparoscopic hysterectomy: a prospective randomized trial. Journal of International Medical Research 2012;40(2):701-8. - PubMed
Long 2005 {published data only}
    1. Long CY, Liu CM, Wu TP, Hsu SC, Chang Y, Tsai EM. A randomized comparison of vesicourethral function after laparoscopic hysterectomy with and without vaginal cuff suspension. Journal of Minimally Invasive Gynecology 2005;12(2):137-43. - PubMed
Lönnerfors 2015 {published data only}
    1. Lönnerfors C, Reynisson P, Persson J. A randomized trial comparing vaginal and laparoscopic hysterectomy vs robot-assisted hysterectomy. Journal of Minimally Invasive Gynecology 2015;22(1):78–86. [DOI: ] - PubMed
Mahmood 2015 {published data only}
    1. Mahmood S, Chowhdury SB, Shamim S, Ara R. A comparative study of abdominal hysterectomy versus vaginal hysterectomy in non descent cases. Mymensingh Medical Journal 2015;24(3):521-7. - PubMed
Martínez‐Maestre 2013 {published data only}
    1. Martínez-Maestre MA, Gambadauro P, González-Cejudo C, Torrejón R. Total laparoscopic hysterectomy with and without robotic assistance: a prospective controlled study. Surgical Innovation 2014;21(3):250–5. [DOI: 10.1177/1553350613492023] - DOI - PubMed
Morelli 2007 {published data only}
    1. Morelli M, Caruso M, Noia R, Chiodo D, Cosco C, Lucia E, et al. Total laparoscopic hysterectomy versus vaginal hysterectomy: a prospective randomized trial. Minerva Ginecologica 2007;59(2):99-105. - PubMed
Moustafa 2008 {published data only}
    1. Moustafa M, Elgonaid WE, Massouh H, Beynon WG. Evaluation of closure versus non-closure of vaginal vault after vaginal hysterectomy. Journal of Obstetrics and Gynaecology 2008;28(8):791-4. - PubMed
Møller 2001 {published data only}
    1. Moeller C, Kehlet H, Schouenborg L, Ottensen B, Friland S, Lund C. Fast track hysterectomy. In: XVI FIGO World Congress Abstract Book 3. Washington DC, 2000:46.
    1. Møller C, Kehlet H, Friland SG, Schouenborg LO, Lund C, Ottesen B. Fast track hysterectomy. European Journal of Obstetrics & Gynecology and Reproductive Biology 2001;98(1):18-22. - PubMed
Nezhat 1992 {published data only}
    1. Nezhat F, Nezhat C, Gordon S, Wilkins E. Laparoscopic versus abdominal hysterectomy. Journal of Reproductive Medicine 1992;37(3):247-50. - PubMed
Oscarsson 2006 {published data only}
    1. Oscarsson U, Poromaa IS, Nussler E, Lofgren M. No difference in length of hospital stay between laparoscopic and abdominal supravaginal hysterectomy--a preliminary study. Acta Obstetricia et Gynecologica Scandinavica 2006;85(6):682-3. - PubMed
Pabuccu 1996 {published data only (unpublished sought but not used)}
    1. Pabuccu R, Atay V, Ergun A, Duru NK, Orhon E, Yenen MC. Laparoscopic assisted vaginal hysterectomy results. In: Human Reproduction: Abstracts of the 12th Annual Meeting of ESHRE. Maastricht 1996;11:235-6.
Pan 2008 {published data only}
    1. Pan HS, Ko ML, Huang LW, Chang JZ, Hwang JL, Chen SC. Total laparoscopic hysterectomy (TLH) versus coagulation of uterine arteries (CUA) at their origin plus total laparoscopic hysterectomy (TLH) for the management of myoma and adenomyosis. Minimally Invasive Therapy 2008;17(5):318-22. - PubMed
Park 2003 {published data only}
    1. Park NH, Kim JW, Seo CS, Kim SH, Song YS, Kang SB, et al. Comparison of two laparoscopic methods of hysterectomy. International Journal of Obstetrics and Gynecology 2003;83(Suppl 3):79.
Petrucco 1999 {published data only (unpublished sought but not used)}
    1. Petrucco OM, Luke C, Moss J, Healy D. Randomized prospective trial comparing laparoscopic assisted vaginal and abdominal hysterectomy. In: IX Annual Scientific Meeting of the Australian Gynaecological Endoscopic Society Abstracts. 1999:75.
Phipps 1993 {published data only}
    1. Phipps JH, John M, Nayak S. Comparison of laparoscopically assisted vaginal hysterectomy and bilateral salpingo-ophorectomy with conventional abdominal hysterectomy and bilateral salpingo-ophorectomy. British Journal of Obstetrics and Gynaecology 1993;100(7):698-700. - PubMed
Polat  2016 {published data only}
    1. Polat M, Kahramanoglu I, Senol T, Senturk B, Ozkaya E, Karateke A. Comparison of the effect of laparoscopic and abdominal hysterectomy on lower urinary tract function, vaginal length, and dyspareunia: a randomized clinical trial. Journal of Laparoendoscopic & Advanced Surgical Techniques 2016;26(2):116-21. [DOI: DOI: 10.1089/lap.2015.0437] - PubMed
Seow 2010 {published data only}
    1. Seow KM, Lin YH, Hwang JL, Huang LW, Pan CP. A simple procedure to prevent chronic vaginal colpotomy wound bleeding after laparoscopically assisted vaginal hysterectomy. International Journal of Gynaecology and Obstetrics 2010;1091(1):49-51. - PubMed
Sulochana 2021 {published data only}
    1. Sulochana M, Sharma SR. Comparative study of laparoscopic assisted vaginal hysterectomy versus total abdominal hysterectomy in benign gynecological conditions. European Journal of Molecular & Clinical Medicine 2022;9(4):1540-4.
Tchartchian 2016 {published data only}
    1. Tchartchian G, Heldmann P, Bojahr B, Larbig A, De Wilde RL. The laparoscopic-assisted combined hysterectomy: a new surgical concept compared to the classical laparoscopic-assisted vaginal hysterectomy by a prospective study. Gynecologic and Obstetric Investigation 2017;82(3):223–9. [DOI: DOI: 10.1159/000447592] - PubMed
Uccella 2018 {published data only}
    1. Uccella S, Malzoni M, Cromi A, Seracchioli R, Ciravolo G, Fanfani F, et al. Laparoscopic vs. transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy. American Journal of Obstetrics and Gynecology 2018;218(5):500.e1-500.e13.. [DOI: 10.1016/j.ajog.2018.01.029] - DOI - PubMed
Wijk 2018 {published data only}
    1. Wijk L, Nilsson K, Ljungqvist O. Metabolic and inflammatory responses and subsequent recovery in robotic versus abdominal hysterectomy: a randomised controlled study. Clinical Nutrition 2018;37(1):99-106. [PMID: ] - PubMed
Yue 2009 {published data only}
    1. Yue Q, Ma R, Mao DW, Dong TJ, Sun L, Geng XX, et al. Effects of laparoscopically-assisted vaginal hysterectomy compared with abdominal hysterectomy on immune function. Journal of International Medical Research 2009;37(3):855-61. - PubMed

References to studies awaiting assessment

Chrysostomou 2021 {published data only}
    1. Chrysostomou A, Djokovic D, Libhaber E, Edridge W, Kawonga M, Herendael BJ. A randomized control trial comparing vaginal and laparoscopically-assisted vaginal hysterectomy in the absence of uterine prolapse in a South African tertiary institution. European Journal of Obstetrics and Gynecology and Reproductive Biology 2021;267:73-7. [DOI: 10.1016/j.ejogrb.2021.10.018] - DOI - PubMed
Sajjad 2021 {published data only}
    1. Sajjad N, Qadir S, Kasi R, Rasheed T, Unar F, Akhtar T. Comparison of post-operative quality of life between vaginal hysterectomy and abdominal hysterectomy. Pakistan Journal of Medical & Health Sciences 2021;15(7):1801-3. [DOI: ]

References to ongoing studies

NCT04886791 {unpublished data only}
    1. NCT04886791. Vaginal hysterectomy versus Vaginal Assisted NOTES Hysterectomy (VANH): a randomised controlled trial. https://clinicaltrials.gov/ct2/show/record/NCT04886791 (first received 26 April 2021). [NETHERLANDS IDTRIAL REGISTER: NL9448]
NCT05031182 {unpublished data only}
    1. NCT05031182. Tolerance of the vNOTES surgical technique in total hysterectomy for benign lesion. Clinical trial of non-inferiority compared to the laparoscopic technique. https://clinicaltrials.gov/ct2/show/NCT05031182 (first received 1 September 2021). [RBHP 2021 CURINIER: 2021-A01218-33]

Additional references

ACOG 2009
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ACOG 2017
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Agostini 2005
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Kreuninger 2018
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References to other published versions of this review

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