Surgical approach to hysterectomy for benign gynaecological disease.

BACKGROUND: The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH). 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 inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms. 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, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS: We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies. AUTHORS' CONCLUSIONS: Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. 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. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any 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 and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.

Laparoscopic surgery for endometriosis.

BACKGROUND: Endometriosis is the presence of endometrial glands or stroma in sites other than the uterine cavity and is associated with pain and subfertility. Surgical interventions aim to remove visible areas of endometriosis and restore the anatomy. OBJECTIVES: To assess the effectiveness and safety of laparoscopic surgery in the treatment of painful symptoms and subfertility associated with endometriosis. SEARCH METHODS: This review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group including searching CENTRAL, MEDLINE, EMBASE, PsycINFO, and trial registries from inception to July 2013. SELECTION CRITERIA: Randomised controlled trials (RCTs) were selected in which the effectiveness and safety of laparoscopic surgery used to treat pain or subfertility associated with endometriosis was compared with any other laparoscopic or robotic intervention, holistic or medical treatment or diagnostic laparoscopy only. DATA COLLECTION AND ANALYSIS: Selection of studies, assessment of trial quality and extraction of relevant data were performed independently by two review authors with disagreements resolved by a third review author. The quality of evidence was evaluated using GRADE methods. MAIN RESULTS: Ten RCTs were included in the review. The studies randomised 973 participants experiencing pain or subfertility associated with endometriosis. Five RCTs compared laparoscopic ablation or excision versus diagnostic laparoscopy only. Two RCTs compared laparoscopic excision versus diagnostic laparoscopy only. Two RCTs compared laparoscopic excision versus ablation. One RCT compared laparoscopic ablation versus diagnostic laparoscopy and injectable gonadotropin-releasing hormone analogue (GnRHa) (goserelin) with add-back therapy. Common limitations in the primary studies included lack of clearly-described blinding, failure to fully describe methods of randomisation and allocation concealment, and risk of attrition bias.Laparoscopic surgery was associated with decreased overall pain (measured as 'pain better or improved') compared with diagnostic laparoscopy, both at six months (odds ratio (OR) 6.58, 95% CI 3.31 to 13.10, 3 RCTs, 171 participants, I(2) = 0%, moderate quality evidence) and at 12 months (OR 10.00, 95% CI 3.21 to 31.17, 1 RCT, 69 participants, low quality evidence). Compared with diagnostic laparoscopy, laparoscopic surgery was also associated with an increased live birth or ongoing pregnancy rate (OR 1.94, 95% CI 1.20 to 3.16, P = 0.007, 2 RCTs, 382 participants, I(2) = 0%, moderate quality evidence) and increased clinical pregnancy rate (OR 1.89, 95% CI 1.25 to 2.86, P = 0.003, 3 RCTs, 528 participants, I(2) = 0%, moderate quality evidence). Two studies collected data on adverse events (including infection, vascular and visceral injury and conversion to laparotomy) and reported no events in either arm. Other studies did not report this outcome. The similar effect of laparoscopic surgery and diagnostic laparotomy on the rate of miscarriage per pregnancy was imprecise (OR 0.94, 95% CI 0.35 to 2.54, 2 studies, 112 women, moderate quality evidence).When laparoscopic ablation was compared with diagnostic laparoscopy plus medical therapy (GnRHa plus add-back therapy), more women in the ablation group reported that they were pain free at 12 months (OR 5.63, 95% CI 1.18 to 26.85, 1 RCT, 35 participants, low quality evidence).The difference between laparoscopic ablation and laparoscopic excision in the proportion of women reporting overall pain relief at 12 months on a VAS 0 to 10 pain scale was 0 (95% CI -1.22 to 1.22, P = 1.00, 1 RCT, 103 participants, low quality evidence). AUTHORS' CONCLUSIONS: There is moderate quality evidence that laparoscopic surgery to treat mild and moderate endometriosis reduces overall pain and increases live birth or ongoing pregnancy rates. There is low quality evidence that laparoscopic excision and ablation were similarly effective in relieving pain, although there was only one relevant study. More research is needed considering severe endometriosis, different types of pain associated with endometriosis (for example dysmenorrhoea (pain with menstruation)) and comparing laparoscopic interventions with holistic and medical interventions. There was insufficient evidence on adverse events to allow any conclusions to be drawn regarding safety.

Endometrial resection and ablation techniques for heavy menstrual bleeding.

BACKGROUND: Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women; it can reduce their quality of life and cause anaemia. First-line therapy has traditionally been medical therapy but this is frequently ineffective. On the other hand, hysterectomy is obviously 100% effective in stopping bleeding but is more costly and can cause severe complications. Endometrial ablation is less invasive and preserves the uterus, although long-term studies have found that the costs of ablative surgery approach the cost of hysterectomy due to the requirement for repeat procedures. A large number of techniques have been developed to 'ablate' (remove) the lining of the endometrium. The gold standard techniques (laser, transcervical resection of the endometrium and rollerball) require visualisation of the uterus with a hysteroscope and, although safe, require skilled surgeons. A number of newer techniques have recently been developed, most of which are less time consuming. However, hysteroscopy may still be required as part of the ablative techniques and some of these techniques must be considered to be still under development, requiring refinement and investigation. OBJECTIVES: To compare the efficacy, safety and acceptability of of endometrial destruction techniques to reduce heavy menstrual bleeding (HMB) in premenopausal women. SEARCH METHODS: We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials CENTRAL), MEDLINE, EMBASE, CINAHL, and PsycInfo, (from inception to June 2013). We also searched trials registers, other sources of unpublished or grey literature and reference lists of retrieved studies, and made contact with experts in the field and pharmaceutical companies that manufacture ablation devices. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing different endometrial ablation techniques in women with a complaint of HMB without uterine pathology were eligible. The outcomes included reduction of HMB, improvement in quality of life, operative outcomes, satisfaction with the outcome, complications and need for further surgery or hysterectomy. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, assessed trials for risk of bias and extracted data. Attempts were made to contact authors for clarification of data in some trials. Adverse events were only assessed if they were separately measured in the included trials. Comparisons were made with individual techniques and an overall comparison between first and second-generation ablation methods was also undertaken. MAIN RESULTS: Twenty five trials (4040 women) with sample sizes ranging from 20 to 372 were included in the review. A majority of the trials had a specified method of randomisation, adequate description of dropouts and no evidence of selective reporting. Less than half had adequate allocation concealment and most were unblinded.There was insufficient evidence to suggest superiority of a particular technique in the pairwise comparisons between individual ablation and resection methods.In the overall comparison of the newer 'blind' techniques (second-generation) with the gold standard hysteroscopic ablative techniques (first-generation) there was no evidence of overall differences in the improvement in HMB (12 RCTs) or patient satisfaction (11 RCTs).Surgery was an average of 15 minutes shorter (mean difference (MD) 14.9, 95% CI 10.1 to 19.7, 9 RCTs; low quality evidence), local anaesthesia was more likely to be employed (relative risk (RR) 2.8, 95% CI 1.8 to 4.4, 6 RCTs; low quality evidence) and equipment failure was more likely (RR 4.3, 95% CI 1.5 to 12.4, 3 RCTs; moderate quality evidence) with second-generation ablation. Women undergoing newer (second-generation) ablative procedures were less likely to have fluid overload, uterine perforation, cervical lacerations and hematometra than women undergoing the more traditional type of ablation and resection techniques (RR 0.18, 95% CI 0.04 to 0.79, 4 RCTs; RR 0.32, 95% CI 0.1 to 1.0, 8 RCTs; RR 0.22, 95% CI 0.08 to 0.61, 8 RCTs; and RR 0.32, 95% CI 0.12 to 0.85, 5 RCTs; all moderate quality evidence, respectively). However, women were more likely to have nausea and vomiting and uterine cramping (RR 2.0, 95% CI 1.3 to 3.0, 4 RCTs; and RR 1.2, 95% CI 1.0 to 1.4, 2 RCTs; both moderate quality evidence, respectively). The risk of requiring either further surgery of any kind or hysterectomy specifically was reduced with second-generation ablative methods compared to first-generation ablation up to 10 years after surgery (RR 0.69, 95% CI 0.48 to 0.99, 1 RCT; and RR 0.60, 95% CI 0.38 to 0.96, 1 RCT; both moderate quality evidence, respectively) but not at earlier follow up. Additional research is required to confirm this finding. AUTHORS' CONCLUSIONS: Endometrial ablation techniques offer a less invasive surgical alternative to hysterectomy. The rapid development of a number of new methods of endometrial destruction has made systematic comparisons between individual methods and with the 'gold standard' first-generation techniques difficult. Most of the newer techniques are technically easier to perform than traditional hysteroscopy-based methods but technical difficulties with the new equipment need to be addressed. Overall, the existing evidence suggests that success, satisfaction rates and complication profiles of newer techniques of ablation compare favourably with hysteroscopic techniques.

Endometrial resection / ablation techniques for heavy menstrual bleeding.

BACKGROUND: Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women; it can reduce their quality of life and cause anaemia. First-line therapy has traditionally been medical therapy but this is frequently ineffective. On the other hand, hysterectomy is obviously 100% effective in stopping bleeding but is more costly and can cause severe complications. Endometrial ablation is less invasive and preserves the uterus, although long-term studies have found that the costs of ablative surgery approach the cost of hysterectomy due to the requirement for repeat procedures. A large number of techniques have been developed to 'ablate' (remove) the lining of the endometrium. The gold standard techniques (laser, transcervical resection of the endometrium and rollerball) require visualisation of the uterus with a hysteroscope and, although safe, require skilled surgeons. A number of newer techniques have recently been developed, most of which are less time consuming. However, hysteroscopy may still be required as part of the ablative techniques and some of them must be considered to be still under development, requiring refinement and investigation. OBJECTIVES: To compare the efficacy, safety and acceptability of methods used to destroy the endometrium to reduce HMB in premenopausal women. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CINAHL, PsycInfo, the Cochrane Central Register of Controlled Trials and the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (from inception to August 2009). We also searched trial registers and other sources of unpublished or grey literature, reference lists of retrieved studies, experts in the field and made contact with pharmaceutical companies that manufactured ablation devices. SELECTION CRITERIA: Randomised controlled trials comparing different endometrial ablation techniques in women with a complaint of heavy menstrual bleeding without uterine pathology. The outcomes included reduction of heavy menstrual bleeding, improvement in quality of life, operative outcomes, satisfaction with the outcome, complications and need for further surgery or hysterectomy. DATA COLLECTION AND ANALYSIS: The two review authors independently selected trials for inclusion, assessed trials for quality and extracted data. Attempts were made to contact authors for clarification of data in some trials. Adverse events were only assessed if they were separately measured in the included trials. MAIN RESULTS: In the comparison of the newer 'blind' techniques (second generation) with the gold standard hysteroscopic ablative techniques (first generation), there was no evidence of overall differences in the improvement in HMB or patient satisfaction.Surgery was an average of 15 minutes shorter (weighted mean difference (WMD) 14.9, 95% CI 10.1 to 19.7), local anaesthesia was more likely to be employed (odds ratio (OR) 6.4, 95% CI 3.0 to 13.7) and equipment failure was more likely (OR 4.6, 95% CI 1.5 to 14.0) with second-generation ablation. Women undergoing newer ablative procedures were less likely to have fluid overload, uterine perforation, cervical lacerations and hematometra than women undergoing the more traditional type of ablation and resection techniques (OR 0.17, 95% CI 0.04 to 0.77; OR 0.32, 95% CI 0.1 to 1.0; OR 0.22, 95% CI 0.08 to 0.6 and OR 0.31, 95% CI 0.11 to 0.85, respectively). However, women were more likely to have nausea and vomiting and uterine cramping (OR 2.4, 95% CI 1.6 to 3.9 and OR 1.8, 95% CI 1.1 to 2.8, respectively). AUTHORS' CONCLUSIONS: Endometrial ablation techniques offer a less invasive surgical alternative to hysterectomy. The rapid development of a number of new methods of endometrial destruction has made systematic comparisons between methods and with the 'gold standard' first generation techniques difficult. Most of the newer techniques are technically easier than hysteroscopy-based methods to perform but technical difficulties with new equipment need to be ironed out. Overall, the existing evidence suggests that success rates and complication profiles of newer techniques of ablation compare favourably with hysteroscopic techniques.

Laparoscopic surgery for pelvic pain associated with endometriosis.

BACKGROUND: Endometriosis is the presence of endometrial glands or stroma in sites other than the uterine cavity. It is variable in both its surgical appearance and clinical manifestation often with poor correlation between the two. Surgical treatment of endometriosis aims to remove visible areas of endometriosis and restore anatomy by division of adhesions and relieve painful symptoms. OBJECTIVES: To assess the efficacy of laparoscopic surgery in the treatment of pelvic pain associated with endometriosis. SEARCH STRATEGY: For the update in July 2009 we searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of trials (searched July 2009), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 2, 2009), MEDLINE (1966 July 2009), EMBASE (1980 July 2009), and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials were selected comparing the effectiveness of laparoscopic surgery used to treat pelvic pain associated with endometriosis, with other treatment modalities or diagnostic laparoscopy only. DATA COLLECTION AND ANALYSIS: Assessment of trial quality and extraction of relevant data was performed independently by two reviewers. MAIN RESULTS: Five studies were included in the meta-analysis, including three full papers and two conference reports. All the randomised controlled trials with the exception of Lalchandani 2003 compared different laparoscopic surgical techniques with diagnotic laparoscopy only. Lalchandani 2003 compared laparoscopic coagulation therapy with diagnostic laparoscopy and medical treatment. Three studies (Abbott 2004; Sutton 1994; Tutunaru 2006) reported the pain scores six months post operatively. Meta-analysis demonstrated an advantage of laparoscopic surgery when compared to diagnostic laparoscopy only (OR of 5.72 95%Cl 3.09 to 10.60 ; 171 participants, three trials, Analysis 1.1). A single study (Tutunaru 2006) reported pain scores twelve months after the procedure. Analysis demonstrated an advantage of laparoscopic surgery when compared to diagnostic laparoscopy only (OR of 7.72 95%Cl 2.97 to 20.06 ; 33 participants, one trial, Analysis 1.1). AUTHORS' CONCLUSIONS: Laparoscopic surgery results in improved pain outcomes when compared to diagnostic laparoscopy alone. There were few women diagnosed with severe endometriosis included in the meta-analysis and therefore any conclusions from this meta-analysis regarding treatment of severe endometriosis should be made with caution. It is not possible to draw conclusions from the meta-analysis which specific laparoscopic surgical intervention is most effective.

Laparoscopy versus laparotomy for benign ovarian tumour.

BACKGROUND: Over the last 10 years laparoscopy and minilaparotomy have become increasingly common approaches for the surgical removal of benign ovarian tumours. However, in the event that a tumour is found to be malignant, laparotomy is the appropriate procedure. Careful preoperative assessment including transvaginal ultrasound with morphological scoring, colour doppler assessment of vascular quality, and serum cancer antigen 125 (CA 125) level is desirable. OBJECTIVES: To determine the benefits, harms, and cost of laparoscopy or minilaparotomy compared with laparotomy in women with benign ovarian tumours. SEARCH STRATEGY: We searched electronic databases, trial registers, and reference lists of published trial reports. Reference lists from trials and review articles were searched. SELECTION CRITERIA: All randomised controlled trials comparing either laparoscopy or minilaparotomy with laparotomy for benign ovarian tumours. DATA COLLECTION AND ANALYSIS: Eight review authors independently assessed the eligibility and quality of each study and extracted the data. MAIN RESULTS: The results of nine randomised controlled trials (N = 482 women) showed that laparoscopic surgery was associated with fewer adverse events of surgery (surgical injury or postoperative complications including fever or infection) (OR 0.3, 95% CI 0.2 to 0.5), less postoperative pain (VAS score WMD -2.4, 95% CI -2.7 to -2.0), greater likelihood of being pain free after two days (OR 7.42, 95% CI 4.86 to 11.33), and fewer days in hospital (WMD -2.88, 95% CI -3.1 to -2.7) than with laparotomy.In one study that reported costs, laparoscopy was associated with a significant reduction in costs compared to laparotomy (WMD - USD 1045, 95% CI -1348 to -742) in 1993. Very high levels of heterogeneity made it inappropriate to pool data on duration of surgery.Three RCTs compared laparoscopy versus minilaparotomy and found that laparoscopy was associated with reduced odds of any adverse event (surgical injury or postoperative complications) (OR 0.10, 95% CI 0 to 0.8) and lower VAS scores for pain (WMD -1.0, 95% CI -1.6 to -0.45). Duration of hospital stay ranged between 1 and 2.2 days, with substantial heterogeneity. AUTHORS' CONCLUSIONS: In women undergoing surgery for benign ovarian tumours, laparoscopy was associated with a reduction in fever, urinary tract infection, postoperative complications, postoperative pain, number of days in hospital, and total cost. These findings should be interpreted with caution since only a small number of studies were identified. These included a total of only 769 women and not all of the important outcomes were reported in each study.

Surgical approach to hysterectomy for benign gynaecological disease.

BACKGROUND: The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions depending on the part of the procedure performed laparoscopically. OBJECTIVES: To assess the most beneficial and least harmful surgical approach to hysterectomy for women with benign gynaecological conditions. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (15 August 2008), CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), EMBASE (1980 to August 2008), Biological Abstracts (1969 to August 2008), the National Research Register, and relevant citation lists. SELECTION CRITERIA: Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included. DATA COLLECTION AND ANALYSIS: Independent selection of trials and data extraction were employed following Cochrane guidelines. MAIN RESULTS: There were 34 included studies with 4495 women. The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections (odds ratio (OR) 0.42), and shorter duration of hospital stay (MD 1.1 days). The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections (OR 0.31) at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection (OR 3.77) and shorter operation time (MD 25.3 minutes). There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding (OR 2.76) were increased in LH. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials. Data were absent for many important long-term outcome measures. AUTHORS' CONCLUSIONS: Because of equal or significantly better outcomes on all parameters, VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH however the length of the surgery increases as the extent of the surgery performed laparoscopically increases. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards.

Laparoscopic surgery.

The generic advantages of avoiding a large laparotomy incision are now well established. For the patient, a laparoscopic procedure is invariably less painful, and recovery and return to full normal activities is more rapid. There are also significant gains in short-term quality of life measures associated with the laparoscopic approach. For the surgeon, improved visualisation offers the opportunity of more precise and accurate surgery. These advantages are usually offset by longer operating times, the use of complex and expensive equipment, and the possibility of new types of complications and increased risk of standard operative morbidity. The aim of this chapter is to identify areas of general technique in which the risks associated with laparoscopic surgery can be minimised while retaining all the advantages of the approach. This is being achieved partly by improved and simplified instrumentation, partly by refinement in techniques, and partly by an increasing awareness of the potential pitfalls of the approach and by adopting strategies to avoid these problems. The majority of gynaecological procedures are already performed endoscopically and all gynaecologists who operate will need to become proficient in these techniques. This chapter outlines techniques for safe laparoscopic entry and safe bipolar diathermy techniques, and describes how to undertake some of the simpler laparoscopic procedures; the evidence supporting these approaches is also presented. Surgical proficiency in safe laparoscopic entry and laparoscopic tubal surgery should lead to the confidence to then undertake more complex procedures.

Health economics of hysterectomy.

Health resources are finite, and it is increasingly necessary to practise medicine within defined budgets. Hysterectomy is recognized as one of the most frequently performed of all major surgical operations and is of great economic as well as medical and social importance. A full assessment of the value of an intervention requires consideration of both economic and clinical outcomes. New alternative therapies to uterine excision have been introduced, and new ways of performing hysterectomy have been developed. Cost-effectiveness analysis enables each of these approaches to be meaningfully compared. Using such analytic techniques, hysterectomy can be shown to be an effective and cost-effective intervention across a variety of indications. The vaginal route is the most cost-effective approach. There seems to be no obvious advantage in conserving or retaining the cervix, but there is as yet no evidence about the cost-effectiveness of concomitant oophorectomy.

A double-blind randomized trial comparing the Cavaterm and the NovaSure endometrial ablation systems for the treatment of dysfunctional uterine bleeding.

OBJECTIVE: To compare two second-generation endometrial ablation systems in women with dysfunctional uterine bleeding (DUB) who want conservative surgical treatment. DESIGN: A double-blind, randomized trial. SETTING: A minimal access gynecological surgery unit in northeast England. PATIENT(S): Fifty-seven women diagnosed with DUB were recruited, with 55 undergoing surgery and completing 12-month follow-up. INTERVENTION(S): Thirty-seven women underwent a NovaSure endometrial ablation, and 18 had a Cavaterm endometrial ablation. Clinical and quality of life data were collected 6 and 12 months after treatment. MAIN OUTCOME MEASURE(S): Amenorrhea, menstrual change, quality of life, sexual activity, patient satisfaction, and procedure acceptability. RESULT(S): Amenorrhea, hypomenorrhea, eumenorrhea, and menorrhagia rates for the Cavaterm and Novasure groups at 12 months were 2/18 (11%) vs. 16/37 (43%); 11/18 (61%) vs. 10/37 (27%); 5/18 (27%) vs. 6/37 (16%); and 0/18 vs. 5/37 (13%), respectively. At 12 months, 83% and 92% of women were either satisfied or very satisfied in the Cavaterm or Novasure groups, respectively. There were no major complications in either group. CONCLUSION(S): Both the Cavaterm and the Novasure endometrial ablation systems are effective in reducing menstrual loss in women with DUB and achieve high rates of patient satisfaction. The Novasure system achieved a statistically significantly higher rate of amenorrhea in this study.

Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial.

OBJECTIVE: To examine the effect on pain and quality of life for women with all stages of endometriosis undergoing laparoscopic surgery compared with placebo surgery. DESIGN: A randomized, blinded, crossover study. SETTING: A tertiary referral unit in a district general hospital. PATIENT(S): Thirty-nine women with histologically proven endometriosis completed the 12-month study. INTERVENTION(S): Women were randomized to receive initially either a diagnostic procedure (the delayed surgical group) or full excisional surgery (the immediate surgery group). After 6 months, repeat laparoscopy was performed, with removal of any pathology present. MAIN OUTCOME MEASURE(S): The end points were changes from baseline values of visual analogue pain scores, validated quality-of-life instruments (EQ-5D and SF-12), and sexual activity questionnaire scores. Patients and assessors of outcomes were blinded to the treatment-group assignment. RESULT(S): Significantly more of the 39 women operated on according to protocol reported symptomatic improvement after excisional surgery than after placebo: 16 of 20 (80%) vs. 6 of 19 (32%); chi(2)(1) = 9.3. Other aspects of quality of life were also significantly improved 6 months after excisional surgery but not after placebo. Progression of disease at second surgery was demonstrated for women having only an initial diagnostic procedure in 45% of cases, with disease remaining static in 33% and improving in 22% of cases. Nonresponsiveness to surgery was reported in 20% of cases. CONCLUSION(S): Laparoscopic excision of endometriosis is more effective than placebo at reducing pain and improving quality of life. Surgery is associated with a 30% placebo response rate that is not dependent on severity of disease. Approximately 20% of women do not report an improvement after surgery for endometriosis.

Psychometric properties of the Body Image Scale in women with benign gynaecological conditions.

OBJECTIVES: To evaluate the psychometric properties of the Body Image Scale (originally designed for use in cancer) in women with benign gynaecological conditions. STUDY DESIGN: Prospective completion of the Body Image Scale by women participating in the EVALUATE Hysterectomy Trial. The scale was completed pre-operatively, then 6 weeks, 4 and 12 months post-operatively. The psychometric properties were evaluated by assessing the reliability, response prevalence, discriminant validity and sensitivity to change. Factor analysis was also conducted to determine the scale structure. RESULTS: The Body Image Scale showed good reliability and clinical validity. Differences between sub-groups of women were detected, demonstrating good discriminant validity. The Body Image Scale was shown to be responsive to changes in body image. CONCLUSIONS: The Body Image Scale was shown to be a reliable and valid tool for assessing body image in women with benign gynaecological conditions and for use in clinical trials involving such women.

Pressure-controlled hysteroscopy during menstruation.

STUDY OBJECTIVE: To document the hysteroscopic appearance of the endometrium at various stages of menstrual shedding and regeneration. DESIGN: Prospective observational study. SETTING: University hospital. PATIENTS: Fourteen women at various stages of the bleeding phase of the menstrual cycle who had not received hormonal therapy during the previous 2 months and who had regular menstrual cycles of 27 to 30 days. INTERVENTION: Twin-channel continuous flow hysteroscopy and careful control of intrauterine pressure. MEASUREMENTS AND MAIN RESULTS: Pressure-controlled hysteroscopy enables a safe and clear view of the endometrium at every stage of the bleeding phase of the menstrual cycle. Menstruation involves piecemeal shedding and concurrent regeneration in adjacent areas. It begins with subepithelial hemorrhage, followed by linear splitting of the surface epithelium and superficial functionalis. Islands of such superficial endometrium are progressively undermined and break free from the underlying tissues. This exposes a mesh of "skeletonized" tubules composed of both glandular stumps and vascular elements. These form the scaffolding for the subsequent reepithelialization and are soon buried beneath a newly formed layer of epithelium and stroma. CONCLUSIONS: Pressure-controlled hysteroscopy enables visualization of the surface appearance of menstrual shedding and regeneration. The process is piecemeal, with zones of rapid shedding and regeneration occurring concurrently over a number of days.

Diagnosis of endometriosis and pelvic pain.

Both the American and the Royal Colleges of Obstetricians and Gynecologists have produced guidelines that recommend patients with chronic pelvic pain, including those suspected of having endometriosis, should receive empirical medical therapy without a preliminary diagnostic laparoscopy. This paper reviews the implications of this approach.

Case report of failed tubal occlusion using Essure pbc (permanent birth control) hysteroscopic sterilisation procedure.

The device previously known as STOP, now called the Essure pbc device, is a dynamic expanding microinsert, placed in the proximal section of the fallopian tube, occluding the tube. Initial reports about the device are promising with occlusion of the tubes in 100% with no reported pregnancies and a high rate of safety and patient acceptability. This report documents the first reported failure of tubal occlusion of an appropriately placed Essure pbc device.

Deeply infiltrating endometriosis affecting the rectum and lymph nodes.

OBJECTIVE: To analyze morphologic aspects of bowel endometriosis. DESIGN: Prospective study of 35 consecutive cases of bowel endometriosis. SETTING: Multidisciplinary group practice and teaching hospital. PATIENT(S): Thirty-five patients with bowel endometriosis were assessed between September 2003 and June 2005. INTERVENTION(S): Histologic analysis of 35 tissue samples removed at laparoscopic rectosigmoidectomy. MAIN OUTCOME MEASURE(S): We performed an evaluation of lesion size, number of lesions present in the bowel, intestinal wall layers affected by the endometriotic lesion, circumference of the intestinal loop affected by the endometriotic lesion, and presence of lymph nodes with foci of endometriosis. RESULT(S): Analysis of the surgical samples revealed lymph nodes in the pericolic adipose tissue of 19 (54%), cases and in 5 of these cases (26.3%), endometriosis had affected the lymph nodes. When the thickness of the endometriotic lesion reached 1.75 cm, lymph nodes of all patients were affected, and all patients in whom more than 80% of the circumference of the intestinal loop was affected by endometriosis presented with positive lymph nodes. CONCLUSION(S): This study raises doubts about whether this form of the disease can still be considered a clinically benign disease.

Excisional surgery versus ablative surgery for ovarian endometriomata: a Cochrane Review.

BACKGROUND: The objective of this review was to determine which is the most effective technique for treating an ovarian endometrioma; excision or ablation. METHODS: A systematic review employing the principles of the Cochrane Menstrual Disorders and Subfertility Group was undertaken. No randomized studies of the management of endometriomata by laparotomy were found. Two randomized studies of the laparoscopic management of ovarian endometriomata of >3 cm in size were included. RESULTS: Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced rate of recurrence of the endometrioma [odds ratio (OR) 0.41, confidence interval (CI) 0.18-0.93], reduced requirement for further surgery (OR 0.21, CI 0.05-0.79), reduced recurrence rate of the symptoms of dysmenorrhoea (OR 0.15, CI 0.06-0.38), dyspareunia (OR 0.08, CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10, CI 0.02-0.56). It was also associated with a subsequently increased rate of spontaneous pregnancy in women who had documented prior subfertility (OR 5.21, CI 2.04-13.29). CONCLUSIONS: There is some evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation, with regard to the recurrence of the endometrioma, recurrence of symptoms and subsequent spontaneous pregnancy in women who were previously subfertile. Consequently this should be the favoured surgical approach. However, we found no data to indicate the best surgical approach in women planning to undergo assisted reproductive techniques.

Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: To evaluate the most appropriate surgical method of hysterectomy (abdominal, vaginal, or laparoscopic) for women with benign disease. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, and Biological Abstracts. SELECTION OF STUDIES: Only randomised controlled trials were selected; participants had to have benign gynaecological disease; interventions had to comprise at least one hysterectomy method compared with another; and trials had to report primary outcomes (time taken to return to normal activities, intraoperative visceral injury, and major long term complications) or secondary outcomes (operating time, other immediate complications of surgery, short term complications, and duration of hospital stay). RESULTS: 27 trials (total of 3643 participants) were included. Return to normal activities was quicker after vaginal than after abdominal hysterectomy (weighted mean difference 9.5 (95% confidence interval 6.4 to 12.6) days) and after laparoscopic than after abdominal hysterectomy (difference 13.6 (11.8 to 15.4) days), but was not significantly different for laparoscopic versus vaginal hysterectomy (difference -1.1 (-4.2 to 2.1) days). There were more urinary tract injuries with laparoscopic than with abdominal hysterectomy (odds ratio 2.61 (95% confidence interval 1.22 to 5.60)), but no other intraoperative visceral injuries showed a significant difference between surgical approaches. Data were notably absent for many important long term patient outcome measures, where the analyses were underpowered to detect important differences, or they were simply not reported in trials. CONCLUSIONS: Significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it brings a higher chance of bladder or ureter injury.