Randomized clinical trials from cen...

Randomized clinical trials from center specializing in endoscopic surgery have reported that laparoscopic hysterectomy is associated with a shorter hospital stay, les discomfort, and a faster answer to normal activities than standard abdominal hysterectomy. These studies have been criticized because they were based in succession small, selected populations. Studies comparing vaginal and laparoscopic hysterectomy techniques generally have shown comparable arises but longer operating times for the laparoscopic approaches. Garry and colleagues used a large multicenter trial to compare the issues of the different techniques using couple parallel randomized trials.

The 43 participating gynecologists in 30 center in Britain and southern Africa recruited more than 1300 women who were scheduled to have hysterectomy for nonmalignant conditions. Participants were required to have no significant medical conditions and a uterine size les than 12 weeks' gestation with no evidence of prolapse. Patients were randomly assigned to the abdominal or vaginal trial, then further randomized to laparoscopic or standard techniques.

Surgical conducts were performed as usual for the surgeon or center Any conversion to an alternative technique was documented. Patients were monitored primarily for major complications while in the hospital and at a six-week clinic visit. Patient data also were gathered at postal questionnaire after four and 12 month Secondary results that were monitored included minor complications, pain (assessed through visual analog scale), analgesia use, sexual activity, dead body image, and general health status.

The women in the four treatment form into groupss were well matched in all significant regards In the abdominal trial, 292 women underwent standard hysterectomy, and 584 had a laparoscopic step Abdominal laparoscopic hysterectomy took longer (median, 84 versus 50 minutes) to perform than abdominal hysterectomy. Similarly, vaginal hysterectomy took longer when laparoscopic techniques were used (72 versus 39 minutes).

Major complications occurr in 65 (111 percent) women in the laparoscopic assemblage which is significantly more than the 18 (62 percent) reported in the abdominal dispose In the vaginal trial, the 168 women undergoing standard hysterectomy had 16 (95 percent) complications compared with 33 (98 percent) in the 336 women undergoing laparoscopic proceedings (see accompanying table). The numbers of patients did not allow statistical conclusions to be drawn comparing vaginal techniques.

The rate of minor complications was comparable (27 versus 25 percent) in patients in the sum of two units abdominal surgery groups. It also was comparable in the couple groups treated vaginally (27 versus 23 percent) Additional pathology--mainly adhesions, endometriosis, and fibroids--was twice as likely to be reported during laparoscopic surgeries in the abdominal and vaginal groups

The median detail of hospital stay after abdominal hysterectomy was single in kind day longer than for laparoscopic abdominal courses but identical in both vaginal clusters Abdominal hysterectomy was significantly more painful than abdominal laparoscopic hysterectomy, moreover pain scores did not differ in the vaginal trial. All measures were associated with improvements in quality of life at four and 12 month Early differences in the abdominal arrange (i.e., body image, sexual activity, and physical aspects of quality of life) versus the laparoscopic collection resolved by 12 months.

The authors decide that laparoscopic hysterectomy is associated with a significantly higher rate of major complications than abdominal hysterectomy and takes longer to perform. by conversion laparoscopic abdominal hysterectomy results in better short-term quality of life, les pain, and more rapid get back to normal activities. In the vaginal approach, the thought did not include sufficient patients to support statistically significant conclusions.

In a related inquiry Sculpher and colleagues conducted a cost-effectiveness analysis of these clinical trials. They estimate that laparoscopy take away froms an average of $328 more than the abdominal performance Laparoscopy costs an average of $708 more than vaginal hysterectomy. In the two groups, no significant difference in overall quality of life was achieved. These authors infer that vaginal laparoscopic hysterectomy is not costliness effective compared with standard techniques, if it were not that the two techniques are balanced in abdominal approaches.

EDITOR'S NOTE: These studies illustrate the importance of negotiating rational and acceptable choices with completely informed patients. Many patients just want--or solely are given--a bottom line opinion from physicians about which surgery is better. Many patients assume that the more recent laparoscopic techniques are intrinsically preferable to standard approaches. These days, family physicians can be involved in several layers of this compages decision. Physicians need to begin the proces of informing patients and helping them work revealed the optimal surgery options before referring them to a gynecologist. Family physicians also are called upon more and more frequently after the surgical consultation to interpret the information that was granted and to help the patient validate the best decision for her. An additional layer can be imposed if insurance companies or other payors apply "cookbook" approaches that do not allow individualized trade-offs between the advantages and disadvantages of the different techniques and always selectively include no other than some costs and outcomes. While this cogitation helps us generalize about the different techniques, data are highly specific to individual surgeon and surgical units. These and other studies are barely general guides, and physicians should be familiar with the issues of their own referral surgeon of that kind data are difficult to ascertain--referral decisions continue to be made forward the basis of collegial have a high opinion of and trust rather than forward hard evidence.--A.D.W.