Advances in laparoscopic surgery have made vaginal hysterectomy in the absence of prolapse obsolete: AGAINST: Vaginal hysterectomy remains the optimum route of surgery

摘要

Why are we still arguing about the optimum technique for hysterectomy when evidence is overwhelmingly in favour of vaginal hysterectomy for benign gynaecological disease? The Cochrane Collaboration published its first systematic review on the surgical approach to hysterectomy in 2005, and concluded: ‘Significantly improved outcomes suggest VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH…’. Updated reviews in 2006, 2009 and 2015 have come to the same conclusion, and relevant to this debate, the most recent version also stated: ‘No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries’ [Aarts JWM et al. Cochrane Database Syst Rev 2015;(8):CD003677]. While our own College is silent on the subject, the American College of Obstetricians and Gynecologists and the Society of Obstetricians and Gynaecologists of Canada have issued guidelines recommending vaginal hysterectomy as the optimum route for surgery (ACOG Committee Opinion. Obstet Gynecol 2009;114:1156–8; Lefebvre G et al. J Obstet Gynaecol Canada 2002;24:37–61). In a press release in 2009, for instance, ACOG stated: ‘Vaginal hysterectomy is the safest and most-effective method to remove the uterus for noncancerous reasons’. Despite the evidence, most hysterectomies are not being done vaginally. There are several reasons for this. Lack of opportunity and training for junior doctors is undoubtedly one explanation, and this becomes a self-fulfilling prophesy as they become the senior gynaecologists of the future, de-skilled in what is one of the few procedures only we can carry out. Laparoscopic surgery is arguably easier to teach and is seen as more exciting, more modern (I expect we will be having the same debate in a few years’ time concerning robotic hysterectomy). There is much money to be made selling expensive laparoscopic equipment, so it is in the industry's interests to promote anything laparoscopic irrespective of the alternative. However, most damning, as concluded in a recent review, is the ‘lack of awareness of evidence supporting vaginal hysterectomy’ (Moen M et al. Obstet Gynecol 2014;124:585–8). Or, for the sceptics amongst us, wilful ignorance. The truth is that if we wanted to act in the best interests of our patients, vaginal hysterectomy should be the default route of surgery in cases of benign pathology. Like our forefathers, we should learn how to perform the surgery in the absence of prolapse, to deal with the enlarged fibroid uterus and to carry out salpingo-oophorectomy vaginally [Davies A et al. American Journal of Obstetrics and Gynecology 1998, 179, 1008–12]. As most women undergoing hysterectomy do not have pelvic floor prolapse, those in charge of training should ensure that vaginal hysterectomy is a core component of the curriculum for trainees interested in benign gynaecological surgery rather than restricting the procedure to the specialist urogynaecologist. Then, perhaps, we would all be performing evidence-based hysterectomies. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.