The Systematic Review And Meta-analysis Of Comparision Among Minor Invasive Surgical Approaches To Hysterectomy For Benign Gynecological Diseases

Background:Hysterectomy is the most common surgery for treating benign gynecological diseases.There're three major approaches to hysterectomy:total abdominal hysterectomy (TAH),total vaginal hysterectomy(TVH) and laproscopical hysterectomy(LH). Recently technigue of TAH has been improved and minilaporotomy hysterec tomy (miniLPT) turned to be an substitution for traditional TAH for significant shorter operation time,less blood loss,quicker recovery and less pain.In the mean time,TVH and LH have been known as less invasive approaches compared with TAH.There's a need of conclusion and analysis for plenty of clinical trials about these minimally invasive methods above.Objective:to compare and assess TVH,LH and miniLPTSearch strategy:We searched CBM,CKNJ,MEDLINE,EMBASE,Cochrane DSR,ACP Journal Club,DARE,CCTR,CMR,HTA,and NHSEED.The types of article include published,ongoing and conference sketch.Selection criteria:randomised clinical controlled trials comparing one surgical approach to another of extrafascial hysterectomy(among TVH,LH,miniLPT) which were done to those women with benigh gynecological diseases.As to economy assessment,cost-effective analysis was permissive.Also permissive were those obsevational researches reporting rare or important longterm outcome.Data collection and analysis: articles were evaluated by GRADE system and principle of Cochrane Reviewer Handbook 4.2.3RCT.Twelve trials that included 2898 participants aged from 34 to 76 were included.When comparable,independent selection of trials and data extraction were employed following Cochrane guidelines.Main results:Cost-effetive analysis showed when in indication of VH,TVH is more cost effetive than LH.When TVH is less but still accessible,meta-analysis showed TVH has significant advantage than the other two approaches in many sides.Comparing with LH arm,Operationg time is shorter(WMD 43.1min,95%CI 28.8 to 57.5 mi n),blood loss is less(WMD 137.0ml,95%CI 95.1 to 178.8ml),hospital stay is shorter (WMD 18.8h,95%CI 13.5 to 24.2h),first stool or to break wind is quicker(WMD 8.1h,95%CI 5.3 to 10.8h) in TVH arm.But in the other side the incident rate of bad wound healing(such as vaginal cuff infection,abdominal wall infection,wound dehiscence,et al),of secondary infection(such as UTI,URI,unknown infection,et al),of febrility were less common in LH arm than in TVH arm with no significant difference. Meanwhile ratio of sexual hypofunction,declined marital life quality,worse body image were more in TVH arm than in LH arm implied LH arm provided a better postoperation sexual life recovery.Operation time is longest in miniLPT arm(WMD 37.0h,95%CI 13.5 to 60.5h) and blood loss is most(WMD 208.5ml,95%CI 41.4 to 375.7ml),too.The febrility rate is also most common in miniLPT arm(Peto OR 3.7, 95%CI 1.1 to 12.4).The diffenrences are significant.Conclusion:TVH is the least invasive approach and better cost effetive when accessible. Howerve the limitations to when is not accessible remain unclear depend on surgeon's own technique and experience and patients' individual condition.LH does better in improving quality of life and body image.Cost effectiveness of LH may become much better by reducing blood loss during operation through improving technique or instument of hemostasis.Limited application of non-reproducible instrument or cost and promotion of their recycle may help a lot in bringing down LH operation cost, too.MiniLPT develops relatively late resulting in less reseaches on it.The advantage of miniLPT should be evaluated more precisely by its technique development and more penetrating researches.There are huge gaps in standadized high quality randomised clinical trials,performance and research about longterm outcome and health economy comparing among different approaches for total hysterectomy in our country.